Loading...
PROOF OF INSURANCE (2024 - 2025)El Segundo Joy Around the World Fesfival of Holidays December Liability Waiver ("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 byvehicle 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 specif tally, but without limitation, any and all forms of personal injury (including death) and property damage to any person, resulting from Contractors 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. e -. D 5-9-d by Satf at 1jWU satya Boddu 51GNE'l° -YRI�V�'f`M.. - 'll.— iz/s/zoza DATE " DATE(MM/DDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 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! . PRODUCER CONTACT The Camp Team NAME: 9035 WADSWORTH PKWY STE 3820 A/c N Ext :A •No); (303) 422-1276 WESTMINSTER, CO 80021-4541 EMAIL _ INSURERA : ........................................................... . .......... ................_........................... ....................._..................................... INSURED SPORTS AND RECREATION PROVIDERS ASSOCIATION (PURCHASING GROUP) AND INSURERS ITS PARTICIPATING MEMBERS: City Of El Segundo INSURERC: 350 Main Street INSURER D : EL SEGUNDO, CA 90245 INSURERS: INSURER F : INSURER(S) AFFORDING COVERAGE NAIC # Great American Insurance Company 16691 rnVFRAnFS rFRTIFIr_ATF NIIMRFR• r,AR1rSWA7 REVISION NUMRER- 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. �... __ .... _. ._.. � ......... LTR TYPE OF INSURANCE .ADDL SUER POLICY NUMBER POLICY EFF POLICY EXP t.TR. '. INSR. wVD MM(DDIYYYY '., MM/OD. LIMITS GENERAL LIABILITY EACH OCCURRENCE $1.000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE I'O RENTED PREMISES (Ea accurr 291 $300,000 CLAIMS -MADE occuR MED EXP (Any one person) $10,000 A X O 12/05/2024 12/06/2024 '.. PERSONAL & ADV INJURY $1,000,000 '.. X HOST LIQUOR LIABILITY INCLUDED PAC 4725036 12:00 AM 12:01 AM - ............ GENERAL AGGREGATE $1,000,000 .. PRODUCTS COMP/OP AGG .............. $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: P Rr.. X POLICY JE`C'l LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accudPr,} ..._. ............................. ... ANY AUTO BODILY INJURY (Per person) •_,,',. ALL OWNED SCHEDULED BODILY INJUft..• (...........__ �•_,Y Per AUTOS AUTOS accident HIRED AUTO �' NON -OWNED PROPERTY DAMAGE ........_,, AUTOS F"¢^er,.ntcnl . ........ ......... UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS -MADE AGGREGATE DED I11.11'-IVT10N $ 12/05/2024 12/06/2024 EACH OCCURRENCE $1,000,000 A, Professional Liability X PAC 4725036 12:00 AM 12:01 AM AGGREGATE LIMIT $1,000,000 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 TP,e� Caws TU1411 ACORD 25 (2016/03) © 1988-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD FOLIE%," NUMBER CAAP0000702924 YEAR MAKE 2023 TESLA NAVED INSURED ,11-DIDI-nONAL DRIVERS DEEPALI VORA Scan the QR code Lo arcec 11"Yi mcy.co/cp. You can dovvni(--)-i %/ CALIFORNIA EVIDENCE OF UA81UT-Y 111'4&-JRA'ICE Mercury Insurance Company P.O. BOY, 10730, SANTA ANA, CA 92711 -0730, F-i= 71 - EFFECTIVE DA! E E� � � '-J 11111/2024 05/11/2025 VIN -r u REPORT A C L A 11-10, p e a se- ROAOSME -2SSISTANCE ONLY [lem'.. - 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: C_) I have and will maintain a certificate of consent of. self-wsure for workers' compensation, issued by the Director of Industrial Relations as provided for by Labor Coate § 3700 for the performance of the work set forted the agreement with the City of EI Segundo. Policy No. (_) 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 EI Segundo is executed. My workers' compensation insurance carrier and policy number are: Carrier Name of Agent Policy Number Expiration Date Phone # Cjt4 I certify that, in the performance of the work sat forth in the agarepmenl with the City of EI Segararadoo 11 will not employ any person in any manner so as to become subpect to the workers" compensation laws of California, and agree that, if I should become subject to the workers' compensaton pro'vi.sians of LaborCode § 17010 1 rraust immediately comply with those previsions or the agreement wilt automatically become void... Signature of Ap Print Name Agreement for: Dated: Reviewed by: Date _ k1Nr.l 01