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PROOF OF INSURANCE (2024) CLOSEDCERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 06/20/2024 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the pollcy(les) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER Gary E. Krouse Insurance Services, Inc. 9620 Topanga Canyon Place, Unit H Chatsworth, CA 91311 INSURED EL SEGUNDO ART WALK, LLC 142 RICHMOND ST El Segundo, CA 90245 INSURER(S) AFFORDING COVERAGE 11 NAIC # American COVERAGES CERTIFICATE NUMBER:1113980 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. _. ..... __.._... INSR POL POL9CY EFF POiICY Ex LTR TYPE OF INSURANCE ICYNUMBER LIMITS MM PJO MM D ZAI COMMERCIAL GENERAL LIABILITY FLM6379633-00 08/23/2024 08/26/2024 EACH OCCURRENCE $ 1.000000 CLAIMS -MADE OCCUR ❑X X X A L= i _C9T[ REM SES' Ea occuf .,... i . rrtlne m __.. FiOSt LtCIUgr MED EXP (An)I one person) $ _...._.. 5.000 y fr, Full LIrq (1.1�00„000 ActO/r. CC1 PERSONAL & ADV INJURY $ ... m1 000 .000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2.000000 POLICY ❑ PRE. LOC JEC'r PRODUCTS-COMP/OPAGG _ _- $ ....... 1 000000 X OTHERt� $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT _IFS MPO-4 P.�) $ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ ������ mmmmm- HIRED NON -OWNED 'ROPER7Y' DAMAGE $ AUTOS ONLY AUTOS ONLY LPr tP. r l $ AG L UMBRELLA LIAB X OCCUR SXS5517660-00 08/23/2024 08/26/2024 EACH OCCURRENCE $ 2 OOQ-Q0,0 X EXCESS LIAR CLAIMS -MADE AGGREGATE .. ............... $ 000 000 .mm�.a .. . DEO RETENTION$ $ WORKERS COMPENSATION STEATUTE I,RH AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE E L EACH ACCIDENT $ OFFICER/MEMBEREXCLUDED7. ❑ (Mandatory In NH) N / A E L DISEASE - EA EMPLOYEE $ If as, describe under DESCRIPTION OF OPERATIONS below ..... E.L. DISEASE- POLICY LIMIT $ Inland Marine FLM6379633-00 08/23/2024 08/26/2024 See Attached DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES Coverage Location: United States $ Canada Event: EL SEGUNDO ART WALK Certificate holder Is named as additional insured and loss payee as their interest may appear. Coverage 2024 Is primary and non-contributory. All coverages expire at 12:01 a.m. Standard Time. " The actual event dates.may be limited. Please review the Scheduled Events form attached to this certificate CITY OF EL SEGUNDO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 350 MAIN STREET THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN EL SEGUNDO, CA 90245 ACCORDANCE WITH THE POLICY PROVISIONS. United States Of America AUTHORIZED REPRESENTATIVE ++" No. I Fax No, ©1'388-201'5 ACORD CORPORATION. All 'rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD This certificate of Insurance does not affirmatively or negatively amend, extend, or alter the coverage afforded by the insurance policy. DATE (MMIDDNY) ADDITIONAL COVERAGE DETAILS 06/20/2024 INSURED EL SEGUNDO ART WALK, LLC The following is attached to and made part of certificate number 1113980. Policy Details Coverage Limit Deductible Inland Marine Company: Zurich American Insurance Company Policy Number: FLM6379633-00 *Period: 08/23/2024 - 08/2612024: 3 Day(s) Equipment, props, sets, wardrobe (rented) 10,000 1,000 Equipment, Props, Sets, Wardrobe (owned) Excluded Rented Furs, Jewelry, Art & Antiques Coverage Excluded Extra Expense Excluded Third Party Property Damage 10,000 1,500 Hired/Non-Owned Physical Damage -Aggregate Excluded Hired/Non-Owned Physical Damage -Per Vehicle Excluded Rental Cost Reimbursement Excluded Waiver of Subrogation Excluded Coverage Extension Endorsement Coverage Extension Endorsement Excluded Terrorism Included General Liability Company: Zurich American Insurance Company Policy Number: FLM6379633-00 *Period: 08/23/2024 - 08/26/2024: 3 Day(s) General Aggregate 2,000,000 Products / Completed Operations 1,006,000 Personal / Advertising Injury 1,000,000 Each Occurrence 1,000,000 Fire Legal 100,000 Medical Payments 5,000 Blanket Additional Insureds (other than city/special carts & Included waivers) City / Other Special Certificates Included Waiver of Subrogation Included Host Liquor Included Liquor Liability -Aggregate 1,000,000 Liquor Liability -Each Common Cause Limit 1,000,000 Abuse & Molestation -Aggregate Excluded Abuse & Molestation -Each Claim Excluded Abusive Act Alleged Participant Supplemental Coverage - Excluded Aggregate Abusive Act Alleged Participant Supplemental Coverage - Excluded Occurrence Participant Legal Liability -Aggregate Limit Excluded Participant Legal Liability - Occurrence Limit - Bodily Injury Excluded Participant Legal Liability - Occurrence Limit - Property Damage Excluded Terrorism Included *All coverages expire at 12:01 a.m. Standard Time, APM-CERT-DETAILS 1009 Certificate Number 1113980 Scheduled Events Certificate Number: 1113980 Event Type Venue Dates Attendees EL SEGUNDO ART EL SEGUNDO ART WALK 08/23/2024 - 08/24/2024 at 12:01 am (Setup) 5,000 Spectators WALK 2024 212 EUCALYPTUS DR AND PARKING 08/24/2024 - 08/25/2024 at 12:01 am Art Festivals LOT OF 314 MAIN STREET 08/25/2024 - 08/26/2024 at 12:01 am (Tear Down) EL SEGUNDO, CA 90245 ABANEV-SCHD(05106) Page 1 of 7 DATE (MMIDDM) SCHEDULE OF FORMS 06/20/2024 Insured: EL SEGUNDO ART WALK, LLC This Schedule of Forms is attached to and made part of certificate number 1113980, as of 06/20/2024 at 10:32 AM PT, and lists the forms included in the policy(s) and subsequent endorsement (s) at the time this certificate was issued. Form # Ed. Name Special Event Package Notices U-GU-319-F 0109 Important Notice - In Witness Clause U-GU-874-BCW 0223 Notice of Disclosure for Agent and Broker Compensation UGU873ACW 0611 Disclosure Statement U-GL-1197-A CW 0104 Asbestos Exclusion Endorsement U-GU-1191-ACW 0315 Sanctions Exclusion Endorsement Common UGU727ACW 0806 Commercial insurance Policy UGU1292ACW 0422 Notice Of Important Provisions UGUD310A 0193 Common Policy Declarations UGU619ACW 1002 Schedule of Forms and Endorsements UGU621ACW 1002 Schedule Of Named Insured(s) UGU618ACW 1002 Schedule Of Locations IL0017 1198 Common Policy Conditions U-GU-1223-B CA 0916 Revised Deflnldon Of Spouse Endorsement UABI100ACW 0117 Schedule Of Productions UABI101ACW 0117 Definition Of Employee UAB100ACW 0117 Minimum Earned Premium Endorsement IL0270 0720 California Changes - Cancellation and Nonrenewal Endorsement IL0003 0908 Calculation of Premium U-GU-630-ECW 0120 Disclosure of Important Information Relating to Terrorism Risk Insurance Act Inland Marine UABMD104ACW 0117 Commercial Inland Marine Declarations Entertainment Program UGU619ACW 1002 Schedule of Forms and Endorsements CM0001 0904 Commercial Inland Marine Conditions UASM133ACW 0117 Common Conditions, Exclusions And Definitions UABM105ACW 0117 Miscellaneous Equipment Coverage Form UABM106ACW 0117 Props, Sets And Wardrobe Coverage Form UABM109ACW 0117 Third Party Property Damage Coverage Form UABM103ACW 0117 Loss Payable Endorsement UABM128ACW 0117 Excluded Property Endorsement UABM114ACW 0117 Unscheduled Production, Presentation Or Event Exclusion UABM100ACW 0117 Stunt, Animal Exposure And Pyrotechnic Exclusion U-GU-767-BCW 0115 Cap on Losses From Certified Acts of Terrorism General Liability UABLD100BCW 0119 Commercial General Liability Coverage Part Declarations UGU619ACW 1002 Schedule of Forms and Endorsements UA81110ACW 1020 Schedule of Events CG0001 0413 Commercial General Liability Coverage Form CG2011 1219 Additional Insured - Managers of Lessors of Premises CG2012 1219 Additional Insured - State or Governmental Agency or Subdivision or Political Subdivision - Permits or Authorizations CG2026 1219 Additional Insured - Designated Person or Organization CG2404 1219 Waiver of Transfer of Rlghls of Recovery Against Others to Us CG2028 1219 Additional Insured - Lessor of leased equipment U-GL-1327-BCW 0413 Other Insurance Amendment - Primary And Non- Contributory UABL128ACW 0117 Additional Insured - Owners Or Lessees Scheduled Person Or Organization Primary and Noncontributory Coverage UABL121ACW 0117 Limited Stationary Aircraft Coverage CG2106 0514 Exclusion -Access or Disclosure or Conndenllai or Personal Information and Data -Related Liability - With Limited Bodily Injury Exception U-GL-1171-B-CW 0719 Fungi Bacteria Exclusion U-GL-1178-A-CW 0703 Asbestos Exclusion CG2147 1207 Employment Related Practices Exclusion U-GL-1517-BCW 0413 Collection or Distribution of Material or Information in Violation of Law Exclusion UABL131ACW 0117 Non -Performing Animal Exclusion UABL102ACW 0117 Property Damage To Rented Premises Exclusion UABL129ACW 0117 Assault And Battery Exclusion UGL1250ACW 0905 Abusive Act Liability Exclusion UABL122ACW 0117 Newly Acquired Or Formed Entity Exclusion UABL107ACW 0117 Exclusion - Insureds Conducting Media, Entertainment, Or Internet Type Operations UABL130ACW 0117 Informational Content Exclusion UABL135ACW 0117 Media Content Exclusion UABL137ACW 0117 Cross Suits Exclusion UABL138ACW 0117 Personal And Advertising Injury - Exclusion Of False Arrest, Detention, Imprisonment, Libel, Slander, Right Of Privacy, Advertising Idea, And Copyright, Trademark Or Trade Secret " UABL106ACW 0117 Unscheduled Production, Presentation Or Event Exclusion UABL103ACW 0117 Stunt, Pyrotechnic And Animal Exposure Exclusion UABL144ACW 1019 Event Conditional Exclusion CG2132 0509 Communicable Disease Exclusion UABL146ACW 1019 Unscheduled Products Exclusion UABL145ACW 1019 Hazardous Activities, Pyrotechnic Activities and Animal Exposure Exclusion UABL147ACW 1019 Loss Arising Out of Participation In a Sports or Athletic Event, Competition, Contest or Exhibition Exclusion APA-CERT-FORMLIST 0914 Certificate Number: 1113960 Pagel of 2 DATE (MWDDNY) w SCHEDULE OF FORMS 06/20/2024 Insured: EL SEGUNDO ART WALK, LLC This Schedule of Forms is attached to and made part of certificate number 1113980, as of 06/20/2024 at 10:32 AM PT, and lists the forms included in the pollcy(s) and subsequent endorsement (s) at the time this certificate was issued. Form # Ed. Name UABL'143ACW 1019 Moshing Excluslon UABL150ACW 1019 Camping Conditional Exclusion UGLD1036BCW 0904 Liquor Liability Coverage Part Declarations CGO033 0413 Liquor Liability Coverage Form IL0021 0908 Nuclear Energy Liability Exclusion Endorsement (Broad Form) UABL105ACW 0117 Commercial General Liability Changes U-GU-767-BCW 0115 Cap on Losses From Certified Acts of Terrorlsm _...._._....� m.._._. ,... ��..-.�,...W,., Excess. .e...._..._.-_� Liability Policy _.m....�m�w..�,�,...�....�,Y.. �__�..__._.-.-�-,�.,.,��,..__...�_...._-._.�.....-__.._-._.._._.._..�..w.�-...zv Excess Liability Notices U-GU-1191-ACW 0315 Sanctions Exclusion Endorsement U-GU-874-BCW 0223 Notice of Disclosure for Agent and Broker Compensation Forms U-SXS-104-ACW 0911 Straight Excess Liability Polley Qacket) UGU621ACW 1002 Schedule Of Named Insured(s) U-SXS-D-100-ACW 0911 Straight Excess Liability Policy Declarations U-SXS-101-ACW 0911 Schedule of Underlying Insurance U-SXS-103-ACW 0911 Schedule of Forms & Endorsements U-GU-630-ECW 0120 Disclosure of Important Information Relating to Terrorism Risk Insurance Act U-SXS-100-ACW 0911 Straight Excess Liability Policy U-GU-767-BCW 0115 Cap on Losses From Certified Acts of Terrorism U-SXS-1 1 7-BCW 0514 Professional Liability Limltatlon Endorsement U-EXS-115-CCW 0411 Communicable Disease Exclusion UEXS319CCW 0514 Liquor Law Liability And Alcohol Consumption Health Hazards Exclusion UEXS101BCW 0411 Abuse Or Molestation Exclusion UEXS107ACW 0499 Athletic Participants Exclusion U-GU-1223-B CA 0916 Revised Definition Of Spouse Endorsement U-EXS-312-FCW 0514 Exclusion - Recording and Distribution of Material or Information in Violation of Law U-EXS-178-BCA 0411 California Cancellation and Nonrenewal U-SXS-120-A CW 0911 Total Pollution Exclusion with Hostile Fire Exception Disclaimers This Certificate of Liability Insurance includes the Type of Insurance, Limits, and Schedule of Forms in effect as of 06/20/2024 at 10:32 AM PT. It does not affirmatively or negatively amend, extend, or alter the coverage afforded by the insurance policy nor confer any rights upon the certificate holder. You may be required to request an updated certificate in the event of subsequent policy modifications. The Information Included In this certificate that has been provided by Abacus Insurance Brokers, LLC is for your information only, and does not create a contract or agency relationship between the carIfficata holder or any insured and Abacus Insurance Brokers, LLC, By accepting this cadificato the certificate holder acknowledges thatAbacus Insurance Brokers, LLC is not the agent of the certificate holder or any Insured, but is solely Ilia agent, of (fie listed carder(s). Abacus Insurance Brokers, LLC makes no representation whether the coverages listed herein are appropriate for the cedifirate holder or any insure, Please review the listed coverages carefully and direct any questions to your broker. For a complete listing of coverages, terms, conditions and exclusions, please view the referenced Pollcy(s). APA-CERT-FORMLIST 0914 Certlfcate Number: 1113980 Page 2 of 2 Date (MM/DDNYYY) Certificate Verification 06/20/2024 Insured: EL SEGUNDO ART WALK, LLC Abacus provides an efficient website lookup tool for certificate holders to verify the authenticity of certificates of insurance. 1. Navigate to the website and input the verification code OR Scan the QR code. 2. The actual certificate issued through the Abacus Platform will download. 3. Compare the details of the downloaded certificate to the certificate presented by the client. Websi e W . _.... ..m_.m1le i oln Meade .... __ ., ....... ._. www.abacus.net/verify-certificate OUOGN8VPJW About Certificates Issued through the Abacus.net Platform • Abacus requires that all certificates be issued through the Abacus Platform. Certificates issued outside of the Abacus Platform are invalid. • Certificates may be issued through the Abacus Platform by either the named insured (if registered through the Abacus Platform) or their Abacus registered insurance broker. • Certificates with any stray marks, cross outs or alterations of any sort are invalid. • Each certificate is numbered and correlates to the document issued through the Abacus Platform. APA-CERTVER 0917 CertiOcate Number: 1113960 Page 1 of 1 DocuSign Envelope ID: 82A3C873-1703-4799-84C3-BC9901 EE8AF2 Gary E. Krouse Insurance Services, Inc. 9620 Topanga Canyon Place, Unit H • Chatsworth, CA 91311 (818) 407-5300 • Fax: (818) 407-5308 • Email: customerservice@krouseins.com Special Events Quote: 715855 (Version 4) Quote Date: 06/19/2024 Client Details Name Contact Address City, St, Zip Premium Summary Description Special Event Package n Inland Marine General Liability Policy Total Excess Liability Policy Excess Liability Policy Total EL SEGUNDO ART WALK, LLC JOHN MCCULLOUGH 142 RICHMOND ST El Segundo, CA 90245 Phone (213) 804-0044 Fax Other Phone Email JOHNMCCU@GMAIL.COM Effective Expiration Premium/Taxes 08/23/2024 08/26/2024 l 112.00 08/23/2024 08/26/2024 1,212.001 1,324.001 08/23/2024 08/26/2024 707.00 707.001 IM 00 Total ... ...._. ��....2, 031 Notes • Premium is fully earned at binding. Premium financing is not permitted. • Coverage under this program is for a single policy term and is not renewable. As such a renewal quote will not be offered. This Quote Is valid until 07/1912024. Any changes will result In this quote becoming Invalid. This quote supersedes all prior quotes. For complete coverage terms, conditions and exclusions, please request a sample pollcy from your broker. This quote Is an offer Year Insurance on the terms set. forth heroin, The quote does riot create a contract or agency retatlonship between the applicant and Abacus Insurance Brokers, LLC. By accepting the offered coverage you acknowledge that Abacus Insurance Breakers, LLC is not the agent of the applicant or the broker, but Is solely ttae agent of the listed carrier(s) end hers Issued the quote on behalf of the carriers). Abacus Insurance Brokers, LLC makes no reprosentatton whether the coverage(s) offered by this quote Is appropriate for your needs. Please revtoww the listed coverage(s) carefuily and direct any questions to your broker. Coverage wIll not be bound unlit recelpt of full payment and Insurance company approval. Coverage cannot be flat cancelled once bound. Date/Time Printed: 06/19/2024 03:35 PM California License #: 0008441 Page 1 of 9 DocuSign Envelope ID: 82A3C873-1703-4799-84C3-BC9901EEBAF2 Gary E. Krouse Insurance Services, Inc. 9620 Topanga Canyon Place, Unit H • Chatsworth, CA 91311 (818) 407-5300 • Fax: (818) 407-5308 • Email: customerservice@krouseins.com Special Events Quote: 715855 (Version 4) Quote Date:06119/2024 Premium and Coverage Summary _ ......... u�-._..Coverage Descriptionv._.�.w _ .. ..m....... .. _.. .._ ._., s.w s.__ .._.�_ ..yLimit� v ....m._ Deductible ,.__�..Premiu.-.. m Special Event Package Inland Marine Zurich American Insurance Company Dates: 08/23/2024 - 08/26/2024, 3 Day(s) Equipment, props, sets, wardrobe (rented) Equipment, Props, Sets, Wardrobe (owned) Rented Furs, Jewelry, Art & Antiques Coverage Extra Expense Third Party Property Damage Hired/Non-Owned Physical Damage -Aggregate Hlred/Non-Owned Physical Damage -Per Vehicle Rental Cost Reimbursement Waiver of Subrogation Coverage Extension Endorsement - Coverage Extension Endorsement Terrorism Total Inland Marine Premium General Liability Zurich American Insurance Company Dates: 08/23/2024 - 08/26/2024, 3 Day(s) General Aggregate Products / Completed Operations Personal/Advertising Injury Each Occurrence Fire Legal Medical Payments Blanket Additional Insureds (other than city/special certs & waivers) City / Other Special Certificates Waiver of Subrogation Host Liquor Liquor Liablllty-Aggregate Liquor Liablllty-Each Common Cause Limit Abuse & Molestation -Aggregate Abuse & Molestation -Each Claim Abusive Act Alleged Participant Supplemental Coverage - Aggregate Abusive Act Alleged Participant Supplemental Coverage - Occurrence Participant Legal Liability -Aggregate Limit Participant Legal Liability - Occurrence Limit - Bodily Injury 10,000 Excluded Excluded Excluded 10,000 Excluded Excluded Excluded Excluded Excluded Included 2,000,000 1,000,000 1,000,000 1,000,000 100,000 5,000 Included Included Included Included 1,000,000 1,000,000 Excluded Excluded Excluded Excluded Excluded Excluded 1,000 1,500 100.00 10.00 2.00 2.00 250.00 100.00 100.00 750.00 This Quote Is valid until 07/19/2024. Any changes will result in this quote becoming Invalid. This quote supersedes all prior quotes. For complete coverage terms, conditions and exclusions, please request a sample policy from your broker. This quote Is an offer for Insurance on the terms set forth herein. The quote does not create a contract or agency relationship between the applicant and Abacus Insurance Brokers, LLC. By accepting the offered coverage you acknowledge that Abacus Insurance Brokers, LLC is not the agent of the applicant or the broker, but is solely the agent of the listed carrier(s) and has Issued the quote on behalf of the carrier(s). Abacus Insurance Brokers, LLC makes no representation whether the coverage(s) offered by this quote Is appropriate for your needs. Please review the listed coverage(s) carefully and direct any questions to your broker. Coverage will not be bound until receipt of full payment and Insurance company approval. Coverage cannot be flat cancelled once bound. Date/Time Printed: 06/19/2024 03:35 PM California License #: 0008441 Page 3 of 9 DocuSign Envelope ID: 82A3C873-1703-4799-84C3-BC9901 EE8AF2 Gary E. Krouse Insurance Services, Inc. 9620 Topanga Canyon Place, Unit H • Chatsworth, CA 91311 (818) 407-5300 • Fax: (818) 407-5308 • Email: customerservice@krouseins.com Special Events Quote: 715855 (Version 4) Quote Date: 06/19/2024 Premium and Coverage Summary Coverage Description _ Participant Legal Liability Occurrence Limit - Property p - Damage Terrorism Total General Liability Premium Policy Total Excess Liability Policy Excess Liability American Guarantee and Liability Insurance Company Dates: 08/23/2024 - 08/26/2024, 3 Day(s) General Aggregate Each Occurrence Terrorism Total Excess Liability Premium Policy Total Limit Deductible Premium Excluded Included 12.00 1,212.00 �a..._1,324. 00 2,000,000 700.00 2,000,000 Included 7.00 _w_, ......-707.00 707.00 This Quote Is valid until 07/19/2024. Any changes will result In this quote becoming Invalid. This quote supersedes all prior quotes. For complete coverage terms, conditions and exclusions, please request a sample policy from your broker, This quote I''s an offer for Insurance on the toners set forth herein. The quote does not create a contract or agency relationship between the applicant and Abacus Insurance Brokers, LLC. By accepting the offered coverage you acknowledge that Abacus Insurance Brokers, LLC is not the agent of the applicant or the broker, but is solely the agent of the listed carrier(s) and has Issued the quote on behalf of the carrier(s). Abacus Insurance Brokers, LLC makes no representation whether the coverage(s) offered by this quote Is appropriate for your needs. Please review the listed coverage(s) carefully and direct any questions to your broker. Coverage will not be bound until receipt of full payment and insurance company approval. Coverage cannot be flat cancelled once bound. Date/Time Printed: 06/19/2024 03:35 PM California License M 0008441 Page 4 of 9 DocuSign Envelope ID: 82A3C873-1703-4799-84C3-BC9901 EE8AF2 Gary E. Krouse Insurance Services, Inc. 9620 Topanga Canyon Place, Unit H • Chatsworth, CA 91311 (818) 407-5300 • Fax: (818) 407-5308 • Email: customerservice@krouseins.com Special Events Quote: 715855 (Version 4) Quote Date: 06/19/2024 Form(s) and Endorsement(s) to be included at time of policy issuance. Form # Edition Name Special Event Package. - Notices U-GU-319-F 0109 Important Notice - In Witness Clause U-GU-874-BCW 0223 Notice of Disclosure for Agent and Broker Compensation UGU873ACW 0611 Disclosure Statement U-GL-1197-A CW 0104 Asbestos Exclusion Endorsement U-GU-1191-ACW 0315 Sanctions Exclusion Endorsement Common UGU727ACW 0806 Commercial Insurance Policy UGU1292ACW 0422 Notice Of Important Provisions UGUD310A 0193 Common Policy Declarations UGU619ACW 1002 Schedule of Forms and Endorsements UGU621ACW 1002 Schedule Of Named Insured(s) UGU618ACW 1002 Schedule Of Locations IL0017 1198 Common Policy Conditions U-GU-1223-B CA 0916 Revised Definition Of Spouse Endorsement UABI100ACW 0117 Schedule Of Productions UABI101ACW 0117 Definition Of Employee UAB100ACW 0117 Minimum Earned Premium Endorsement IL0270 0720 California Changes - Cancellation and Nonrenewal Endorsement IL0003 0908 Calculation of Premium U-GU-630-ECW 0120 Disclosure of Important Information Relating to Terrorism Risk Insurance Act Inland Marine UABMD104ACW 0117 Commercial Inland Marine Declarations Entertainment Program UGU619ACW 1002 Schedule of Forms and Endorsements CM0001 0904 Commercial Inland Marine Conditions UABM133ACW 0117 Common Conditions, Exclusions And Definitions UABM105ACW 0117 Miscellaneous Equipment Coverage Form UABM106ACW 0117 Props, Sets And Wardrobe Coverage Form UABM109ACW 0117 Third Party Property Damage Coverage Form UABM103ACW 0117 Loss Payable Endorsement UABM128ACW 0117 Excluded Property Endorsement UABM114ACW 0117 Unscheduled Production, Presentation Or Event Exclusion UABM100ACW 0117 Stunt, Animal Exposure And Pyrotechnic Exclusion U-GU-767-BCW 0115 Cap on Losses From Certified Acts of Terrorism General Liability UABLD100BCW 0119 Commercial General Liability Coverage Part Declarations UGU619ACW 1002 Schedule of Forms and Endorsements UABI110ACW 1020 Schedule of Events CG0001 0413 Commercial General Liability Coverage Form CG2011 1219 Additional Insured - Managers of Lessors of Premises CG2012 1219 Additional Insured - State or Governmental Agency or Subdivision or Political Subdivision - Permits or Authorizations CG2026 1219 Additional Insured - Designated Person or Organization CG2404 1219 Waiver of Transfer of Rights of Recovery Against Others to Us CG2028 1219 Additional Insured - Lessor of leased equipment U-GL-1327-BCW 0413 Other Insurance Amendment - Primary And Non- Contributory UABL128ACW 0117 Additional Insured - Owners Or Lessees Scheduled Person Or Organization Primary and Noncontributory Coverage UABL121ACW 0117 Llmlted Stationary Aircraft Coverage CG2106 0514 Exclusion -Access or Disclosure of Confidential or Personal Information and Data -Related Liability - With Limited Bodily Injury Exception U-GL-1171-B-CW 0719 Fungi Bacteria Exclusion U-GL-1178-A-CW 0703 Asbestos Exclusion CG2147 1207 Employment Related Practices Exclusion This Quote Is valid until 0711912024. Any changes will result In this quote becoming Invalid. This quote supersedes all prior quotes. For complete coverage terns, conditions and exclusions, ptease request a sample poiicy from your broker. This quote Is an offer for Insurance on the terms set forth herein, The quote doers not create a contract or agency relationship between the applicant and Abacus Insurance Brokers, LLC. By accepting the offered coverage you acknowledge that Abacus Insurance Brokers, LLC is not the agent of the applicant or the broker, but Is solely the agent of the listed carrler(s) and has Issued the quote on behalf of the carrlels) Abacus insurance Brokers, LLC makes no representation whether the coverage(s) offered by this quote Is appropriate for your needs. Please review the listed coveraga(s) carefully and direct any questions to your broker. Coverage wltl not be bound until receipt of full payment and 'insurance company approval. Coverage cannot be flat cancelled once bound. Date/Tlme Printed: 06/19/2024 03:35 PM California License #; 0008441 Page 5 of 9 DocuSign Envelope ID: 82A3C873-1703-4799-84C3-BC9901EE8AF2 Gary E. Krouse Insurance Services, Inc. 9620 Topanga Canyon Place, Unit H - Chatsworth, CA 91311 (818) 407-5300 • Fax: (818) 407-5308 • Email: customerservice@krouseins.com Special Events Quote: 715855 (Version 4) Quote Date: 06/19/2024 Form(s) and Endorsement(s) to be included at time of policy issuance. Form # Edition Name U-GL-1517-BCW 0413 Collection or Distribution of Material or Information in Violation of Law Exclusion UABL131ACW 0117 Non -Performing Animal Exclusion UABL102ACW 0117 Property Damage To Rented Premises Exclusion UABL129ACW 0117 Assault And Battery Exclusion UGL1250ACW 0905 Abusive Act Liability Exclusion UABL122ACW 0117 Newly Acquired Or Formed Entity Exclusion UABL107ACW 0117 Exclusion - Insureds Conducting Media, Entertainment, Or Internet Type Operations UABL130ACW 0117 Informational Content Exclusion UABL135ACW 0117 Media Content Exclusion UABL137ACW 0117 Cross Suits Exclusion UABL138ACW 0117 Personal And Advertising Injury - Exclusion Of False Arrest, Detention, Imprisonment, Libel, Slander, Right Of Privacy, Advertising Idea, And Copyright, Trademark Or Trade Secret UABL106ACW 0117 Unscheduled Production, Presentation Or Event Exclusion UABL103ACW 0117 Stunt, Pyrotechnic And Animal Exposure Exclusion UABL144ACW 1019 Event Conditional Exclusion CG2132 0509 Communicable Disease Exclusion UABL146ACW 1019 Unscheduled Products Exclusion UABL145ACW 1019 Hazardous Activities, Pyrotechnic Activities and Animal Exposure Exclusion UABL147ACW 1019 Loss Arising Out of Participation in a Sports or Athletic Event, Competition, Contest or Exhibition Exclusion UABL143ACW 1019 Moshing Exclusion UABL150ACW 1019 Camping Conditional Exclusion UGLD1036BCW 0904 Liquor Liability Coverage Part Declarations CGO033 0413 Liquor Liability Coverage Form IL0021 0908 Nuclear Energy Liability Exclusion Endorsement (Broad Form) UABL105ACW 0117 Commercial General Liability Changes U-GU-767-BCW 0115 Cap on Losses From Certified Acts of Terrorism Excess Liability Policy Excess Liability Notices U-GU-1191-ACW 0315 Sanctions Exclusion Endorsement U-GU-874-BCW 0223 Notice of Disclosure for Agent and Broker Compensation Forms U-SXS-104-ACW 0911 Straight Excess Liability Policy Qacket) UGU621ACW 1002 Schedule Of Named Insured(s) U-SXS-D-100,ACW 0911 Straight Excess Liability Policy Declarations U-SXS-101-ACW 0911 Schedule of Underlying Insurance U-SXS-103-ACW 0911 Schedule of Forms & Endorsements U-GU-630-ECW 0120 Disclosure of Important Information Relating to Terrorism Risk Insurance Act U-SXS-100-ACW 0911 Straight Excess Liability Policy U-GU-767-BCW 0115 Cap on Losses From Certified Acts of Terrorism U-SXS-117-BCW 0514 Professional Liability Limitation Endorsement U-EXS-115-CCW 0411 Communicable Disease Exclusion UEXS319CCW 0514 Liquor Law Liability And Alcohol Consumption Health Hazards Exclusion UEXS101BCW 0411 Abuse Or Molestation Exclusion UEXS107ACW 0499 Athletic Participants Exclusion U-GU-1223-B CA 0916 Revised Definition Of Spouse Endorsement U-EXS-312-FCW 0514 Exclusion - Recording and Distribution of Material or Information in Violation of Law U-EXS-178-BCA 0411 California Cancellation and Nonrenewal U-SXS-120-A CW 0911 Total Pollution Exclusion with Hostile Fire Exception This Quote Is valid until 07/1912024. Any changes will result in this quote becoming Invalid. This quote supersedes all prior quotes. For complete coverage terms, conditions and exclusions, please request a sample policy from your broker. This quote is an offer for Insurance on the terms set forth herein. The quote does not create a contract or agency relationship between the applicant and Abacus Insurance Brokers, LLC. By accepting the offered coverage you acknowledge [hat Abacus Insurance Brokers, LLC is not the agent of the applicant or the broker, but is solely the agent of the listed carrier(s) and has Issued the quote on behalf of the carder(s). Abacus Insurance Brokers, LLC makes no representation whether the coverage(s) offered by this quote Is appropriate for your needs. Please review the listed coverage(s) carefully and direct any questions to your broker. Coverage will not be bound until receipt of full payment and insurance company approval. Coverage cannot be flat cancelled once bound. Date/Time Printed: 06/19/2024 03:35 PM California License #: 0008441 Page 6 of 9 DocuSign Envelope ID: 82A3C873-1703-4799-84C3-BC9901 EE8AF2 Gary E. Krouse Insurance Services, Inc. 9620 Topanga Canyon Place, Unit H • Chatsworth, CA 91311 (818) 407-5300 • Fax: (818) 407-5308 • Email: customerservice@krouseins.com Special Events Quote: 715855 (Version 4) Quote Date: 06/19/2024 Major Exclusions Products Liability Limitation Products liability Is Included only for sales of the following products: Food and Beverages, Sound and Image Media, Souvenirs (including but not limited to: Posters, Badges, Programs, Apparel, Toys, Stickers) Excluded Activities This Insurance does not apply to the following activities (unless endorsed by underwriters onto o the policy): Circus and Carnivals Mechanical Amusement Devices Motorized Sporting Events Tractor/Truck Pulls Aircraft and Balloon Events Professional Sporting Activities Body piercing Bungee jumping Hang gliding Hot air ballooning Kayaking Motorcycle riding Mountain or rock climbing Parachuting Parasailing Playing in or on any bounce house or other inflatable play structure Racing using a land vehicle, aircraft, or watercraft Riding on amuzement rides Scuba diving Skateboarding Skydiving Stage diving or Tattooing Additional Excluded Activities Stunts, Pyrotechnics, Aircrafts, Animals, Hazardous Activities, Car Races, Precision Driving, Mechanical Amusement Devices, Events outside U.S., Film Production Note Excess Liabilityis excess over the general liability y Q ' g labili and auto only. It is not excess over liquor coverage, third party property damage, abuse or molestation, employee benefits, participants legal liability. This Quote Is valid until 07/t9/2024. Any changes will result in this quote becoming Invalid. This quote supersedes all prior quotes. For complete coverage terms, conditions and exclusions, please request a sample policy from your broker. This quote Is an offer for Insurance on the torms set forth herain.'The quote does not create a contract or agency relationship between the applicant and Abacus Insurance Brokers, LLC. By accepting the offered coverage you acknowledge that Abacus Insurance Brokers, LLC Is not the agent of the applicant or the broker, but is solely the agent of the listed carder(s) and has Issued the quote on behalf of the carrler(s). Abacus Insurance Brokers, LLC makes no representation whether the coverage(s) offered by this quote Is appropriate for your needs. Please review the listed coverage(s) carefully and direct any questions to your broker. Coverage will not be bound until receipt of full payment and insurance company approval. Coverage cannot be flat cancelled once bound. DateTme Printed: 06/19/2024 03:35 PM California License #: 0008441 Page 7 of 9 DocuSign Envelope ID: 82A3C873-1703-4799-84C3-BC9901 EE8AF2 Gary E. Krouse Insurance Services, Inc. 9620 Topanga Canyon Place, Unit H • Chatsworth, CA 91311 (818) 407-5300 • Fax: (818) 407-5308 • Email: customerservice@krouseins.com Special Events Quote: 715855 (Version 4) Quote Date:06/19/2024 Event Event Type Event Name Event Dates Event Cost/Budget Event Description Artist/Band Celebrities Spectator Attendance Participant Attendance Venue Event Location Vendors # of Attractions # of Exhibitors # of Concessions (Food) # of Concessions (Non Food) Event Details Art Festivals EL SEGUNDO ART WALK 2024 08123/2024 - 08/24/2024 at 12:01 am (Setup) 08/24/2024 - 08/25/2024 at 12:01 am 08/25/2024 - 08/26/2024 at 12:01 am (Tear Down) $10,000 EVENT DESCRIPTION EL SEGUNDO ART WALK FEATURING 4 BLOCK BY 4 BLOCK AREA OF LOCAL ARTISTS, 35 INDIVIDUAL BUSINESS, PARTIAL STREET CLOSURE OF EUCALYPTUS AND LIVE MUSIC FROM 3-9PM. BEER GARDEN LOCATED BOTH AT 212 EUCALYPTUS DRIVE AND PARKING LOT AT 314 MAIN STREET IN EL SEGUNDO. VENUE 212 EUCALYPTUS. L PET PROJECT (None) 5,000 (5,000 for 1 day(s)) 0 EL SEGUNDOART WALK, 212 EUCALYPTUS DR AND PARKING LOT OF 314 MAIN STREET EL SEGUNDO, CA 90245, United States Of America Outdoor 0 0 0 0 Auto IIr"�ruosure Hired and Non -Owned Auto Coverage has not been selected This Quote Is valid until 07119/2024. Any changes will result In this quote becoming Invalid. This quote supersedes all prior quotes. For complete coverage terms, conditions and exclusions, please request a sample policy from your broker, This quote is an offer for Insurance on the terms set forth hereln. The quote does not create a contract or agency relationship between the applicant and Abacus Insurance Brokers, I.I.C. By accepting the offered coverage you acknowledge that Abacus Insurance Brokers, LLC is not the agent of the applicant or the broker„ but Is solely the agent of the listed carrier(s) and has Issued the quote on behalf of the carrier(s). Abacus Insurance Brokers,, LLC makes no representation whether the coverage(s) offered by this quota Is appropriate for Your needs. Please review the listed coverage(s) carefully and direct any questions to your broker. Coverage will not be bound until receipt of full payntent and Insurance company approval. Coverage cannot be flat cancelled once bound. Date/Time Printed: 06/19/2024 03:35 PM California License #: 0008441 Page 8 of 9 DocuSign Envelope ID: 82A3C873-1703-4799-84C3-BC9901 EE8AF2 Gary E. Krouse Insurance Services, Inc. 9620 Topanga Canyon Place, Unit H - Chatsworth, CA 91311 (818) 407-5300 • Fax: (818) 407-5308 • Email: customerservice@krouseins.com Special Events Quote: 715855 (Version 4) Quote Date:0611912024 Application Summary The following outlines the details you have provided about your business. We have relied on the accuracy of this information in order to present this quote. If any of the items below are Incorrect or have changed, please contact your insurance broker so that we can update your quote. Your Business Business Name Business Address Contact Details Business Entity Type Business Details - Operations Statements About your Business Underwriting Questions EL SEGUNDO ART WALK, LLC 142 RICHMOND ST El Segundo, CA 90245 JOHN MCCULLOUGH, E-mail: JOHNMCCU@GMAIL.COM, Phone: (213) 804-0044 Individual EVENT PLANNING 1. Does the event include any of the following? No Stunts, Pyrotechnics, Aircrafts, Hazardous Activities, Car Races, Precision Driving, Mechanical Amusement Devices, Film Production 2. The event will take place in the United States or Canada? Yes 3. Confirm only one event can be covered per policy. Yes 4. Any bounce houses or inflatables? (If yes, certificates of insurance are required) No 5. Any private armed security? No (i.e. armed security that work exclusively for you under your employ) History Insurance History 1. Any insurance declined or cancelled In the past 3 years? No 2. Any loss in the past 3 years? No 3. Any prior insurance coverage? No 0mau8tgtne+t by: �- p ;FBA0039400.,. ._............... Signature 6/19/2024 Date This Quote Is valid until 07119/2024. Any changes will result In this quote becoming Invalid. This quote supersedes all prior quotes. For cornplate coverage terms, conditions and exclusions, please request a sample policy from your broker. This quote Is an offer for Insurance on the terms set forth herein, The quota does not create a contract or agency relationship between the appllcant and Abacus Insurance Brokers, LLC, By aocepting the offered' coverage you acknowledge that Abacus Insurance Brokers, LLC is not the agent of the applicant or The broker, but is solely the agent of the tfsted carner(s) and has issued the quote on behalf of the carder(s). Abacus Insurance Brokers, LLC makes no representation whether the coverage(;) offered by this quote Is approprlato for your needs„ Please revtew the 0sted coverage(s) carefully and direct any questions to your broker, Coverage will not be bound until receipt of Coil payment and insurance company approval. Coverage cannot be flat cancelled once bound. Date/Tlme Printed: 06/19/2024 03:35 PM California License #: 0008441 Page 9 of 9 DocuSign Envelope ID: 82A3C873-17034799-84C3-BC9901EE8AF2 0 ZURICH THIS DISCLOSURE DOES NOT GRANT ANY COVERAGE OR CHANGE THE TERMS AND CONDITIONS OF ANY COVERAGE UNDER ANY POLICY. DISCLOSURE OF IMPORTANT INFORMATION RELATING TO TERRORISM RISK INSU�RANCE ACT SCHEDULE* Premium attributable to risk of loss from certified acts of terrorism for lines of insurance subject to TRIA: Inland Marine: 2.00, General Liability: 12.00, Excess Liability: 7.00 *Any information required to complete this Schedule, if not shown above, will be shown in the quote or proposal. A. Disclosure of Premium In accordance with the federal Terrorism Risk Insurance Act ("TRIA")„ as amended, we are required to provide you with a notice disclosing the portion of your premium„ if any, attributable to the risk of loss from terrorist: acts certified under that Act for lines subject to TRIA. That portion of premium attributable is shown in the Schedule above, The premium shown in the Schedule above is subject to adjustment upon premium audit, if applicable. B. Disclosure of Federal Participation in Payment of Terrorism Losses You should know that where coverage is provided by this policy for losses resulting from certified acts of terrorism, the United States Government may pay up to 80% of insured losses exceeding the statutorily established deductible paid by the insurance company providing the coverage. C. Disclosure of $100 Billion Cap on All Insurer and Federal Obligations If aggregate insured losses attributable to terrorist acts certified under TRIA exceed $100 billion in a calendar year (January 1 through December 31) and an insurer has met its deductible under the program, that insurer shall not be liable for the payment of any portion of the amount of such losses that exceeds $100 billion, and in such case insured losses up to that amount are subject to pro rata allocation in accordance with procedures established by the Secretary of Treasury. D. Availability As required by TRIA, we have made available to you for lines subject to TRIA coverage for losses resulting from acts of terrorism certified under TRIA with terms, amounts and limitations that do not differ materially from those for losses arising from events other than acts of terrorism. E. Definition of Act of Terrorism under TRIA TRIA defines "act of terrorism" as any act that is certified by the Secretary of the Treasury, in accordance with the provisions of the federal Terrorism Risk Insurance Act ("TRIA"), to be an act of terrorism. The Terrorism Risk Insurance Act provides that the Secretary of Treasury shall certify an act of terrorism: 1. To be an act of terrorism; 2. To be a violent act or an act that is dangerous to human life, property or infrastructure; 3. To have resulted in damage within the United States, or outside of the United States in the case of an air carrier (as defined in section 40102 of Title 49, United States Code) or a United States flag vessel (or a vessel based principally in the United States, on which United States income tax is paid and whose insurance coverage is subject to regulation in the United States), or the premises of a United States mission; and 4. To have been committed by an individual or individuals as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. No act may be certified as an "act of terrorism" if the act is committed as part of the course of a war declared by Congress (except for workers' compensation) or if losses resulting from the act, in the aggregate for insurance subject to TRIA, do not exceed $5,000,000. U-GU-632-E CW (01/20) Copyright © 2020 Zurich American Insurance Company Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission. DECLINATION OF TERRORISM COVERAGE AND PREMIUM PAYMENT The Terrorism Risk Insurance Act of 2002 mandates that you be provided the opportunity to obtain coverage for certified acts of terrorism as defined by that act. To obtain that coverage, you must remit the premium specified on the notification you received informing you of the availability of coverage. You may reject this coverage for any or all of the lines of business shown below. To reject coverage, simply mark the box in front of the line, sign and date this form, and return to us. Note: Failure to sign and return this form will not place coverage in effect. Coverage can only be in force if the required premium has been paid. [] Auto (including liability, physical damage, uninsured motorists, and personal injury [] protection) Inland Marine LJ General Liability El Excess Liability [0 All coverages (if this box is checked, there is no need to check any other) Signing and returning thisfonn.ornotpayn0dhmraqu|redpnanium.viUnenultinonendnmmmendbnynur policy excluding coverage for certified acts mfterrorism. Policy Signature Date ABATERRIDECLNEO42O DocuSign Envelope ID: 82A3C873-1703-4799-84C3-BC9901EEBAF2 a Fraud Warnings Disclosure ZHRICH Property and Casualty Application Addendum TO BE ATTACHED TO AND FORM PART OF THE APPLICATION. IF FRAUD WARNINGS ARE INCLUDED IN THE APPLICATION TO WHICH THIS IS ATTACHED, THIS DISCLOSURE REPLACES THOSE WARNINGS. Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which may subject the person to criminal and civil penalties. (Not applicable in AL, AR, CA, CO, DC, FL, KS, KY, LA, MD, ME, MN, NJ, NM, NY, OH, OK, OR, PA, PR, RI, TN, TX, VA, VT, WA, and WV.) In Arkansas, Louisiana, Rhode Island, or West Virginia: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. In Alabama: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution, fines or confinement in prison, or any combination thereof. In California: For your protection, California law requires the following to appear on this form: Any person who knowingly presents false or fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. In Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. In District of Columbia: Warning: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. In Kansas: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written, electronic, electronic impulse, facsimile, magnetic, oral, or telephonic communication or statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act. In Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. In Tennessee or Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. U-GU-1147-C CW (01/22) Page 1 of 2 DocuSign Envelope ID: 82A3C873-1703-4799-84C3-BC9901EE8AF2 In Maryland: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. In Minnesota: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. In New Jersey: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. In New Mexico: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES. In New York: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. In Ohio: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. In Oklahoma: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. In Oregon: Any person who knowingly and with intent to defraud any insurer or other person files an application for insurance or statement of claim containing any materially false information upon which an insurer relies, if such information was either material to the risk assumed by the insurer or the misinformation was provided fraudulently, may commit a fraudulent insurance act, which may be a crime and may subject the person to criminal and civil penalties. In Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. In Puerto Rico: Any person who has committed fraud, as defined in the law, shall incur a felony, and if convicted, shall be sanctioned for each violation by a penalty of a fine of not less than five thousand dollars ($5,000), nor more than ten thousand dollars ($10,000), or a penalty of imprisonment for a fixed term of three (3) years, or both penalties. If there were aggravating circumstances, the fixed penalty thus established may be increased up to a maximum of five (5) years; if extenuating circumstances are present, it may be reduced to a minimum of two (2) years. In addition to the penalties provided in this chapter, any person who, as a result of the fraud thus committed is benefited in any way to obtain insurance, or in the payment of a loss pursuant to an insurance contract, shall be imposed the payment of restitution of the amount of money resulting from the fraud. Every violation shall have a prescription term of (5) five years. In Texas: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. In Vermont: Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law. In Virginia: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. U-GU-1147-C CW (01/22) Page 2 of 2