PROOF OF INSURANCE (2025 - 2025)SegundoEl World
Festival
December 2024
Liability Waiver
Andrew Hanlen ("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.
SIGNED: w6v& PRINTED: Andrew Hanlen
DATE: 12/4/2024
FRATORD-01
1401cOR0, DATE (MMIDDIYYYY)
414� ITITITITITITITCERTIFICATE OF LIABILITY INSURANCE........
WNSURANC*E _ 1112 /20244
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 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
g s d norsemelTt s this certificate does not confer ri hts to the certificate holder in lieu of such e _ ....._„ ................ ..
PRODUCER hO TTACT zlacqui Gibson
Alera Group Nevada PHONE FAX
9555 Hillwood Drive Suite 140 (Arc„ No, Exi): (70) 304-7801 (AIC, No)r
Las Vegas, NV 89134 A Ess Jacqu,e.Oibsorfl aleragroup.com
tNSURER(S) AFFORDING COVERAG.F..... NAIC #
INSURERA:PPIfladelphia Indemnity 18058
INSURED INSURERS:
Fraternal Order of Real Bearded Santas (FORBS) INSURER C
23052 Alicia Pkwy H-255 INSURER D c
Mission Viejo, CA 92692
INSURER E
INSURER F :
COVERAGESmC CERTIFICATE NUMBER:
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.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 _..--------_........-... ..... ,..FwODL SUSS�t POILICY EFF POLICY EXP
POLICY NUMBER
...._ ---.. TYPE OF INSURANCE,. INSI,S.,,_M_IT�yr��p,'pYYYY'N ,_„„,„
„-,-„ LIMBS ...�....._.. ..I
A x, COMM ERG IAL.GENE .RALLIABILITY
EACH OCCURRENCE S 1"000°000
CLAINIS,MAOE X OCCUR PHPK2600535-012 OPT 1 10/1/2024 10/1/2025
X I
DAMAGE TO RENTED 100,000
dSN:
EF&9wM�aT„Ea d�carrefYrlr.`el , S .......
4E0 EkP (Array wM o pew son) S_
1,000,000
PERSONAL A ADV INJURY' S
GENI. AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE S 2,000,000
. POLICY F-] PRO- LOC
`J JECT
b'�CwOr7'UGTSC.t',}MPPOII ACO , $.... 2,000,000
X OTHER. Per member
..-
$
AUTOMOBILE LIABILITY
C„OMBINFD SINGLE LIMIT $
Ma ucidefl0
ANY AUTO
BODILY INJURY (Per pe,rspn)
OWNED SCHEDULED
.. ...$. _
AUTOS ONLY AUTOS
BODILY INJURY (Per accident),$.....
HIRED NON -OWNED
AUTOS ONLY AUTOS ONLY
11'C1PERTYf)AMAGE
I ea Wx dsdal:! _$..
UMBRELLA LIAB OCCUR
EACH OCCURRENCE $_.....
EXCESS LIAB CLAIMS -MADE
AGGREGATE $
DED RETENTION S
........._........_...................... ._ . ._ _.._......
WORKERS COMPENSATION
PER OTH"
STATUTE
AND EMPLOYERS' LIABILITY YIN
.ER ....
ANY PROPRIETOR/PARTNERIEXECUTIVE --
', NIA
E,L, EACH ACCIDENT S
OFFICER/MEMBER EXCLUDED?
- (Mandatory in NH)
I,..L DISEASE EAF%w)(,Ori•Im, 5...--.-.
If yes, describe under
F
DESCRIPTION ORATIONS below
OF OPERATIONS _ .._
,iF .;.. I,1I$E��AtSk - POC.gi:Y LIMIT '�
y, r __ wwwwwwwww
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES ACORO 101, Additional Remarks Schedule, may be attached if more space is required)
Coverage includes "Abuse & Molestation" with Imits of $100,000 per occurrence/ $500,000 aggregate for this member. This coverage only applies with
acceptable background check verified by or on file with FORBS.
Re: Santa portrayal by FORBS member Andy Hanlen. City of El Segundo is included as an Additional Insured with regards to the General Liability.
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of El Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
y 9 ACCORDANCE WITH THE POLICY PROVISIONS.
350 Main Street
El Segundo, CA 90245 --- ._.......... ._... ....... _....
AUTHORIZED REPRESENTATIVE
ACORD 25 (2016/03) ..... _ _0 1988-2015 ACO............ __...._.. _..
RD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
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.
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.
(__) 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
Name of Agent
( ) I certify that, in the pe
employ any person in any
agree that, if I should b
immediately comply w thrh
Signature of Applicant ..'
Print Name Andreju -Wa
Agreement for:
Dated:.
Reviewed by:
Policy Number Expiration Date
Phone #
;e of the work set forth in the agreement with the City of El Segundo, I will not
so as to become subject to the workers' compensation laws of California, and
aject to the workers' compensation provisions of Labor Code § 3700 1 must
isbns or the agreement will automatically become void,
Date 10/23/24