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PROOF OF INSURANCE (2024 - 2025)El Segundo Joy Around the World 7 ti Festival of Holidays December 1 4 Liability Waiver Klezmer Band ("Contractor") will participate in the City of El Segundo's ("City")Joy Around the World/Festival of Holidays 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 include, 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 authorized 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 facilities throughout the Event. Contractor's entry onto public property for all purposes associated with the Event constitutes an acknowledgment that such premises and all facilities and equipment were inspected and that Contractor finds and accepts them as being safe and reasonably suited for the purposes of Contractor's participation in the Event. By reading, signing and dating this document, Contractor hereby waives, releases, discharges, and covenants, not to sue and hold harmless the City of El Segundo, its officials, agents, sponsors, and/or employees ("Releasees") from and all damages, losses, fines, claims, suits, expenses (including attorney fees and defense costs for Council acceptable to City), judgments and/or liabilities of any form or nature resulting from Contractor's negligence, misconduct, or participation in the event, which includes, without limitation Contractor's travel to and from the Event, whether by vehicle or other means. This release of liability 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 specifically, but without limitation, any and all forms of personal injury (including death) and property damage to any person, resulting from Contractor's negligence, misconduct, or participation in the event, which includes, without limitation Contractor's 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 any participation in the Event. Contractor agrees that the foregoing release and waiver is intended to be as broad as inclusive as permitted under state of California law and that, if any portion is held invalid, 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 consideration for the Event and further agree that no oral representations, statements, or inducement apart from the foregoing written agreement have been made. Gustavo Bulgach SIGNED: PRINTED: 12/5/2024 DATE: ` CERTIFICATE OF LIABILITY INSURANCE12/04/DATE(/2024 Y) 024 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 NAME: v ^ ........ .............. 'y ....... The Cam Team -1276 9035 WADSWORTH PKWY STE 3820 A/CPHONE EI4F Nu Ext,)_......._ iNo): (303) 422 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 I EL SEGUNDO, CA 90245 INSURERE: INSURER F : COVERAGES CERTIFICATE NUMBER: GAS155937 INSURER(S) AFFORDING COVERAGE NAIC # Great American Insurance Company 16691 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 LTR TYPE OF INSURANCE .ADDL 'INSR SI16R wVD POLICY NUMBER POLICY EFF MMIDD/YYYY PDLICYEXP MWOO/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $1,000,000 X COMIVII::.RCIAI. GENERAL UABILITY ESOEa om rr PREMISES PREMISES [Ea acsurrenrz. $300,000 CLAIMS -MADE [:X:] QCOUR EX MED P (Any one person) $10,000 A °"""""' X 12/05/2024 12/06/2024 PERSONAL & ADV INJURY $1,000,000 X HOST LIQUOR LIABILITY INCLUDED PAC 47255036 12:00 AM 12:01 AM -•— .... GENERAL AGGREGATE $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PERY� PRODUCTS - COMP/OP AGG $1,000,000 POLICY Q LOC AUT OMOBILE LIABILITY COMBINED SINGLE LIMIT awldenl ANY AUTO BODILY INJURY (Per person) ALL OWNED SCHEDULED BODILY INJURY (Per AUTOS AUTOS accident HIREDAUTO NON -OWNED F PROPERTY DAMAGE AUTOS (Per amidanp UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LIAB CLAIM. -MADE AGGREGATE DED RETENTION $ 12/05/2024 12/06/2024 A Professional Liability X EACH OCCURRENCE $1,000,000 PAC 4725036 12:00 AM 12:01 AM AGGREGATE LIMIT $1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / 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 -rk,& Gam-Teaaw ACORD 25 (2016/03) © 1988-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER EFFECTIVE DATE EXPIRATION DATE CAA nAAM! 4 41A 2 10123/202.44 041 3/202'5 YEAR MAKE VIN 2000 HONDA NAMED INSURED CYNTHIA, BU L.G AC H-HILL ADDITIONAL DRIVERS GUSTAVO BULGACH TO REPORT A CLAIM, please call (800) 503-3724 For access to ROADSIDE ASSISTANCE ONLY, please call (866) 519-6478 This insurance complies with CVC §16056 or §16500.5 NAIC # 27553 K hold it°ihall': hiiilue 11111111 THE COVERAGE PROVIDED BY THIS POLICY MEETS THE MINIMUM LIABILITY LIMITS PRESCRIBED BY LAW. This card must be carried in the insured motor vehicle for production upon demand. Any alteration will void this card. Any binder or policy, issued thereon is void if any check, money order„ credit charge, ACH, or other non -cash method of payment is not honored when first presented. • Notify the police immediately. • Write down names, addresses, telephone numbers, driver license numbers, and license plate numbers of all persons involved and witnesses. • Please note any damage to other vehicles and take photos if possible. • Do not admit fault. Do not discuss the accident with anyone except your agent, Mercury, or the police. Immediately report all claims to Mercury at (800) 503-3724. ID -CA 03/2023 CITY OF EL SEGUNDO WORKERS' COMPENSATION DECLARATION WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SUBJECTS AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN LABOR CODE § 3706, INTEREST, AND ATTORNEY'S FEES. I affirm under penalty of perjury under the laws of California one of the following declarations; (_) I have and will maintain a certificate of consent of self -insure for workers' compensation, issued by the Director of Industrial Relations as provided for by Labor Code § 3700 for the performance of the work set forth the agreement with the City of El Segundo. Policy No. C—) I have and will maintain workers' compensation insurance as required by Labor Code § 3700 for the performance of the work for which the agreement with the City of El Segundo is executed. My workers' compensation insurance carrier and policy number are: Carrier Policy Number Expiration Date Name of Agent Phone # (x ) I certify that, in the performance of the work set forth in the agreement with the City of El Segundo, I will not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that, if I should become subject to the workers' compensation provisions of Labor Code § 3700 1 must immediately comply with those provisions or the agreement will automatically become void. •'` °" Signature of Applicant Date s 1 to 9iz4 Print Name Gustavo Bulgach Agreement for: Dated: Reviewed by: