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PROOF OF INSURANCE (2024 - 2025)OV :oegund-o, joy Aroiund the Festival of Holidays December 5, 2024 Liability Waiver A g�v .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. Amadou Fall SIGNED: �`�' ''r' PRINTED., DATE: 12/4/2024 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(s). PRODUCER CONTACT The Camp Team PHONE FAX (303) 422-1276 9035 WADSWORTH PKWY STE 3820 AIC. No, Ext : APC Na ; WESTMINSTER, CO 80021-4541 EMAIL ADDRESS:...�.�.- INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: Great American Insurance Company 16691 INSURED SPORTS AND RECREATION PROVIDERS ASSOCIATION (PURCHASING GROUP) AND INSURER B i ITS PARTICIPATING MEMBERS: INSURERC; City Of El Segundo 350 Main Street INSURER D s EL SEGUNDO, CA 90245 W...... INSURERE: '.. INSURER F :. 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. INSR _ ADDL SUBIR POLICY EPP POLICY EXP LIMITS LTR TYPE OF INSURANCE INSR W1/D POLICY NUMBER MMIDDM'YY (MM/DD/YYYY) GENERAL LIABILITY EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED $300,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence) CLAIMS -MADE OCCUR MED EXP (Any one person) $10,000 12/05/2024 12/06/2024 ' A X HOST LIQUOR LIABILITY INCLUDED X PAC 4725036 PERSONAL 8 ADV INJURY $1,000 000 12:00 AM 12:01 AM GENERAL AGGREGATE $1,000,000 ..... ......... GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS COMP/OP AGG $1,000,000 PRO- X POLICY ,/F,Cp LOC COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY Fa acnidann ANY AUTO BODILY INJURY (Per person) ALL OWNED SCHEDULED BODILY OWJUnJfRY(Pmr AUTOS AUTOS arcdenfl ......... HIRED AUTO NON -OWNED PROS cRa t DAMAGE AUTOS UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LIAB HCLAIMS-MADE AGGREGATE DED RETENTION $ PAC 4725036 12/05/2024 12/06/2024 EACH OCCURRENCE $1,000,000 A Professional Liability X 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 TILL-e. ca " .;' Tea,"' ACORD 25 (2016/03) © 1988-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD I State Farm ® t terbmi Providing Insurance and Financial Services PO Box 23M Bloomington IL 61702.2358 Attached as requested are your replacement insurance identification cards. If the attached cards are not accepted by a law enforcement agency or your Department of Motor Vehicle office, please contact your agent to receive additional assistance. Thankyou for choosing State Farm foryour insurance needs. ----------------------------------------- IMPORTANT - IDENTIFICATION CARDS STATE FARM ttf�tf',..,� W_.. ........ CALIFORNIA Statf efffH �' THIS CARD MUST BE KEPT IN THE INSURED MOTOR jai INSURANCE CARD VEHICLE FOR PRODUCTION UPON DEMAND. Palm Mutual Automobile Insurance Company ut 23N Bloomington IL 61702.2359 IED LACY, JAMIE MUTL VOL POLICYNUMBER 6239544-BOI-75E EFFECTIVE YR 2020 MAKE LEXUS AUG 01 2024 TO FEB 01 2025 MODEL RX350 VIN 2T2AZMAA1LC157504 AGENT KUWAE INS AGENCY INC 3621-A75 PHONE 31R00�$111-391M NAIC 2"5'178 PRESCRIBED BY LAW.DED BY RlE POLICY MEETS THE MINIMUM LIABILITY LIMITS COVERAGES A C D500 G500 H U U1 IF YOU HAVE AN ACCIDENT - NOTIFY THE POLICE IMMEDIATELY 1. Get mamus, adaftesses, and pfaoanir numtlars of persons involved and witnesses. Also, get driver ficanse numbers of persons im Ned and license plate rlumt ersiataites of vehicles. 2. Di admit halt or discuss the accadere walh anyone but State Farm or police. 3. omptV� notify your agent, log on to statefarm.com®, or use the State Farm mobile asp to fafa a claim. for EMERGENCY ROAD SERVICE u*IMStart form rnobiioapp'Ia onI stelefarmc am, orcall 1 A77 M Y 7. EXfINE POLICY E%t2. "ONS CAREPi1f Y. THIS FORM DOES NOT CONSTITUTE ANY PART OF YOUR INSURANCE POLICY. How to identify your coverage. See policy for full name and definition A liability H Emergency Road Service U Utni Motor Vchielt C Madicalfasyoraeni PirorcalDorm go U1 Uninsured Motor Vehicle PO D C(tai naahensive R1 Cer Nittaland Fo aviO fxp#trises Z Loss of Earnings G Cali S Doolit, Ctro'saeon brrnv n end Lass olSduht KEEP A CARD IN YOUR CAR. THIS CARD IS INVALID IF THE POLICY FOR WHICH IT WAS ISSUED LAPSES OR IS TERMINATED. KEEP YOUR CURRENT CARD UNTIL THE EFFECTIVE DATE OF THIS CARD. ONE COPY OF THIS FORM SHOULD BE CARRIED IN THE VEHICLE AT ALL TIMES. THE FORM MAY BE NEEDED AS EVIDENCE OF INSURANCE IN COURT. SUBMIT ONE CARD, OR A PHOTOCOPY OF A CARR WITH YOUR VEHICLE REGISTRATION RENEWAL Emergency Road Service information is located on your insurance card. .�. — . ... .. — — — — --.- """"" — — — -Y-- ---. — — — -.-- ---- — -..- —...-. — — — — — — — — — — — — — �� IMPORTANT - IDENTIFICATION CARDS STATE FARM StateftTn CALIFORNIA INSURANCE CARD State Farm Mutual Automobile Insurance Company PO Box 2358 Bloomington IL 61702.2358 INSURED LACY, JAMIE MUTL VOL POLICY NUMBER 623 9544-SOI-75E EFFECTIVE YR 2020 MAKE LEXUS AUG 012024 TO FEB 012025 MODEL RX350 WN 2T2A2MAA1LC157504 AGENT KEVIN KUVWAE AGENCY INC 3621-A75 PHONE PlO '16.3900 NAh3 25178 G ..� VIRED BY THE POLICY MEETS THE MINIMUM LIABILITY LIMITS BED BY LAW. C.. I AGES A C D500 G500 H U Ui tcJtLmvTf THIS CARD MUST BE KEPT IN THE INSURED MOTOR VEHICLE FOR PRODUCTION UPON DEMAND. a� IF YOU HAVE AN ACCIDENT - NOTIFY THE POLICE IMMEDIATELY 1. Get names, aditasses, and phone numbers of pefsom mvofved and witnesses. get driver Ilcerasa numtners of persons Invo wed and license plate nurcnbershomes of vehdepat 2. Don't admit foist or *tugs the aocldeatt with anyone but Slata Farm or police. 3. Icr'omj naalfl a�ycur agent, log on to statefarm.coni or use the State Farm mobile a pp to f le as c For EMERGENCY ROAD SERVIC'EiilbaStow farm mobilaapp�,f��o�nantostalefarmcomorcall 1 877ri27.575L EMINE POLICY EXCLU ONS CAREi�Ui.LY. THIS 1-0RM DOES NOT CONSTf TUTS ANY PART OF YOUR INSURANCE POLICY. How to identify your coverage. See policy for full name and definition A Liability H Iu rrgoirooyRmaalSafvao U Uuinsuted Motor Vehicle C Medical Payments PhyikalOanuago U1UlrawswedMotor Vehicle PO D Comprehensive R1 Car Iteaaal and Trevel I,-mienses Z toss at Esmings G Collision S Death, Dismemberment and Loss oaf Sial�at ... KEEP A CARD IN YOUR CAR. THIS CARD IS INVALID IF THE POLICY FOR WHICH IT WAS ISSUED LAPSES OR IS TERMINATED. KEEP YOUR CURRENT CARD UNTIL THE EFFECTIVE DATE OF THIS CARD. ONE COPY OF THIS FORM SHOULD BE CARRIER M THE V 'CLE AT ALL "TIMES,, THE FORM MAY BE NEEDED AS EVIDENCE OF INSURANCE IN COURT. SUBMIT ONE CARD, OR A PHOTOCOPY OF A CARD, WITH YOUR VEHICLE REGISTRATION RENEWAL 143295.3 (oieccald) 01-15-2018 Emergency Road Service information is located on your insurance card. .R1N 10 2024 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. (_) 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 # LX) 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 g pp s thegreement will automatically become void. immediately comply with fbca pray `c ^ Date 12/2/2024 n Signature of Applicant Print Name Amadou Fall Agreement for: Amadou Fall aka Ame Kora Dated November 12, 2024 Reviewed by: