Loading...
PROOF OF INSURANCE (2024 - 2025)El Segundo a' Around a a „ oli"'days Festival of H Liability 'W Giver ractoro) will participate do the City of 'El Segundo°s ("icily"} Joy Around the World/ Iva of hi'olidays event (the "Event') pursuant to an agreement with the City. Contractor understands that participation in the Event is not without risk to Contractor and others. These intrude, without limitation, risks of physical injury, mental Injury, emotional distress, trauma, death, contact with other participants, and property damage. All risks are known and appreciated by Contractor. Contractor waives any and' all specific notice of the existence of risks. Contractor assumes responsibility for and will pay (if any) medical and emergency expenses In the event of injury, illness, or other incapacity regardless of whether I amhorized such expenses. "Contractor" includes Contractor's employees, officers, or other agents: Contractor agrees and represents that it has inspected, or immediately upon entering Main St./ City Hall Plaza, will inspect the premises and facilifiWs. throughout the Event. Contractor's entry onto public property for all purposes associated with the Event constitutes an acknowledgment that such premises and all faciti6es and equipment were inspected and that Contractor finds and accepts them as. being safe and reasonatrly suited for the purposes of Contractor's partiiptrtion in the Event. By reading, signing and dating this cIOcumentr Contractor hereby waives, releases,r dlsd)argesr and covenants, not to sue and hold harmless the City of El Segundo, its offldabr agents, sponsors, and/or employees ("Releasees") from and all damages, losses, firwes, Maims, suits, expenses (inciluding attomey fees and defense costs for Council acceptable to.City), judgments and/or liabilities of a ny form or nature resulting from Contractor's negligence, misconduct, or participatW In the event, which includes, without 11m6tation Contractor's travel to and from the Event, whether by vehicle or other means. This release of liablllty Includes, but is not limited to any injury, death, sickness or personal injury or property damage Contractor may suffer while on or around the premises where the Event is held. This release also includes specffically, but without limitation, any and all forms of personal injury (inducting death) and property damage to any person, resulting from Contractor's negligence, misconduct, or participatlan In the event, which Includes, without limitation Contractors travel to and from the Event, whether by vehicle or other means, and Contractor expressly assume the risk of such damages or injuries and losses throughout arry participation in the Event, Contractor agrees that the foregoing release and waiver is intended to be as brand as Inclusive as permitted under state of California law and that, If any portion Is held In4alid, it is agreed that the balance will, notwithstanding, continue in full legal force and effect. The undersigned warrants that he or she has legal authority to bind Contractor and that Contractor fully understands and agrees to the above terms and conditions In Dansideration for the Event and further agree that no oral representations, statements, or inducement apart from the foregoing written agreement have been made_ SIGNED: w M ; iliiTEl_+ DATE. ... `III CERTIFICATE OF LIABILITY INSURANCE DATE(04/2024 Y' 12/04/2024 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 policy(ies) must 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 CONTACT The Camp Team NAME: FAX 9035 WADSWORTH PKWY STE 3820 _PHONNo. AIC, Nod (303) 422-1276 WESTMINSTER, CO 80021-4541 E-MAIL - ............................�.._ ..._ ............,� INSURERA : INSURED SPORTS AND RECREATION PROVIDERS ASSOCIATION (PURCHASING GROUP) AND INSURER B: ITS PARTICIPATING MEMBERS:.................. — City Of El Segundo INSURERC: 350 Main Street INSURER D : EL SEGUNDO, CA 90245 INSURERE: INSURER F : INSURER(S) AFFORDING COVERAGE NAIC # ............... _ ........ Great American Insurance Company 16691 COVERAGES CERTIFICATE NUMBER: GAS155937 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. ___.._.__ ........ _ ADDL POLICY EFF PM/oD EXP INSR' TYPE OF INSURANCE WVDsusPOLICY NUMBER .LTR INSR wVD iMM/DD/yYYY MMIDDIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $1,000,000 �.W COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED ...-.......... ................. $300,000 _X�ta,rr:�.�o�ranrti CLAIMS -MADE OCCUR MED EXP (Any one person) 000 A/� 0. •.�.. i X 12/05/2024 12/06/2024 PERSONAL & ADV INJURY �$10 $1,000,000 X HOST LIQUOR LIABILITY INCLUDED ���..___............ PAC 4725036 12:00 AM 12:01 AM ....... GENERAL AGGREGATE $1,000,000 ................. ... GENL AGGREGATE LIMIT APPLIES PER: _ ..... PRODUCTS - COMP/OP AGG $1,000,000 X POLICY PE4 I..00 AUTOMOBILE LIABILITY CCirtawideO SINGLEIM L'rr' !Ea accidenk�_ ANY AUTO BODILY INJURY (Per person) .._.....' ALL OWNED SCHEDULED '�. .._......�,.._._..........�...... BODILY INJURY (Per AUTOS AUTOS accident) HIRED AUTO NON -OWNED _.. PROPERTY DAMAGE AUTOS Per acciden{1 UMBRELLA LIAB OCCUR EACH OCCURRENCE AGGREGATE EXCESS LIAB CLAIMS -MADE DED RETENTION $ A Professional Liability X 12 4 12/06/ EACH OCCURRENCE $1,000,000 PAC 4725036 12:00 A AM 12:01 AM AM AGGREGATE LIMIT $1,000,000 :00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Covered Activities: Christmas Tree Lighting Event/Festival The Certificate Holder is added as an additional insured but only with respect to liability arising out of the named insured during the policy period. Scheduled Activities Exclusion Applies -Please Refer to Named Insured Member Certificate of Coverage CERTIFICATE HOLDER CANCELLATION City of El Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 350 Main Street BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN El Segundo, CA 90245 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE -rt'& Cawf. -r a ' ACORD 25 (2016/03) © 1988-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD OF IMUMAIN muciW lmwaftv compamy PA wilola SWAAn. c&%mtq4nD mf, MC- 104VIOU &A Wyk" NIIIIIIIII4llll&'YW1' hITm R p °4 TO *MWt IOW, CIIAK 0004111 WmW106 a,,oty, *eaks,w,mniWXAW7"liw`f�N«rruUM ?�r�,�'.OWN ii,Auraff&O,- O �"W+„, Ykme k4 W tea, a 19 kA M,"WWO1,19 If "a QF4 Eats tr Como w ft =us=' am G4= tr owl apm jolwall Ny w ad as sa. aM Amq OVW or pa1q qwo nw.a a we Y w 0", nwl sft G=k WWJC AM Qary MP -MA wirof d?ftPW4 w 10 • '�OTllq POIGI 41d!kW4 . R'qM WIM"m tots IUMM a Pyaw 4� AW mm%W IN cow maieim"d$MEph3"Jsaf ■ ODaaok �M llR BQ RcEAo1s M iCOdIK wa g7ti awl i�� � ww> 4IF"PS d• s Wwald"l Mew 914bm IN Moon it MI aALW7k 04tA MIST ! CITY OF EL SEGUNDO WORKERS' COMPENSATION DECLARATION WARNING, FAILURE TO SECURE WORKERS' CO#APENSATIONi COVERAGE IS UNLAWFUL AND SUBJECTS ,AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINE$ UP TO ONE HUNDRED THOUSAND DOLLARS ($1 ,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN LABOR CODE �§ 370, INTEREST, AND ATTORNEY'S FEES. I affirm under penalty of perjury under the laws of California one of the following declarations; (_) II have and will maintain a certificate of consent of self insure for workers' compensation, issued by the Director of Industnal Relations as provided for by Labor Code § 37LI for the performance of the a rk set forth the agreement with the C4 OfEl Segundo, Policy No. L_) I have and will maintain workers' compensation insurance as required by Labor Cade § 3700 fog the performance of the work for wN0 the agreement with the City of El Segundo is executed My workers' compensation insurance ca,frier and policy nurrib r are., Carrier ppppo Policy Number Expiation Dale Name of Agent Phone # 4 nertft that, in the pert rnance of the work set forth in the agreement with the City of El Segundo, I will not emptoy any person in any manner so as to become subject to the wroh(era' compensaton laws of California, and agree that, if I should become subject to the workers' compensation provis-mims of LaMar Code § 3700 1 must irnmedlatlely oomply with th pr90ions or the agrpeTenl #01 iubomaticcally become void. Signature of Applicant Print Narita Agreement far: [dated: Reviewed by: Date . SIG — 6 �.