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PROOF OF INSURANCE (2024 - 2025)IS El Segundo Joy Around the World Festival of Holidays rG_ Liability Waiver Shiho Tendou ("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: PRINTED: Shiho Siegert DATE: Dec 4th, 2024 ` R 12/04/CERTIFICATE OF LIABILITY INSURANCE 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 The Camp Team PHONE PAX 9035 WADSWORTH PKWY STE 3820 Aro N% Ezt : AIC No c (303) 422-1276 WESTMINSTER, CO 80021-4541 EIS. INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: Great American Insurance Company ................... .. 16691 _ ..._ INSURED SPORTS AND RECREATION PROVIDERS ASSOCIATION (PURCHASING GROUP) AND .......... INSURER B ITS PARTICIPATING MEMBERS: ............... City Of El Segundo INSURERC 350 Main Street INSURERD; EL SEGUNDO, CA 90245 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. CN.SR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR wVD MMIDD MM/DD/YYYY GENERAL LIABILITY EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED $300,000 x.. COMMERCIAL GENERAL LIABILITY PREMISES (Ea—wence) CLAIMS -MADE OCCUR MED EXP (Any one person) $10,000 12/05/2024 12/06/2024 PERSONAL & ADV INJURY $1,000 000 q �( HOST LIQUOR LIABILITY INCLUDED x PAC 4725036 12:00 AM 12:01 AM GENERAL AGGREGATE $1,000,000 ........_. ...... _ ....-........ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS COMP/OP AGG $1,000000 PRO- ( POLICY ,gEC:'IX' LOC ' COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY Ea acadenll ANY AUTO BODILY INJURY (Per person) ALL OWNED SCHEDULED .....� BODILY INJURY (Per ............... AUTOS AUTOS aocident HIRED AUTO NON -OWNED PROPERTYDAMAGE Per araJden() AUTOS UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LIAR CLAIMS -MADE AGGREGATE DED RETENTION $ 12/06/2024 EACH OCCURRENCE $1,000,000 A Professional Liability x PAC 4725036 P2/05/2024 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 350 Main Street El Segundo, CA 90245 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Tl,& Ga411.p TeOA— ACORD 25 (2016/03) © 1988-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Get your digital proof of insurance & membership card on the AAA App X>Download the app. Click AAA.com/app75 Els ahatic proof of i 5uvaawc mvyrtel be a did cm rmx: l In all slates, Please keep your hard copy version on hand, Mod be a arnmif AAA member and insured Ihla Wg 9 /w&� to u{e thrs tecalutlr Available fu Whom& and smartphones for Android-, Message, dada and rmranluag roles may apply. -- _-___ California Evidence of Liability Insurance eInterinsurance Exchange of the Automobile Club o NAIC #: 15598 Named Insured Policy Number: CAA130916694 JOSHUA Date: 08/05/2024 Expiration Date: 08/05/2025 This policy complies with Sections 16056 or 16500.5 of the California Vehicle Code. Coverage subject to policy terms and limits. -------------------------------------------- " r VEHICLES ON POLICY YEAR MAKE 2018 INFI Q50 3.OT it w x 0 DRIVERS ON POLICY SIEGERT, SIEGERT, SHIHO VEH I.D. # JNIEV7AR6JM432246 YOU HAVE AN ACCIDENT CALL OUR 24/7 AAA CLAIMS HOTLINE 1-800-672®5246 After an accident, exchange information with the other party and I follow these 5 easy steps: u a mStep 1: Pull vehicle over to a safe place. Get the names, addresses, I w and phone numbers of all persons involved in the accident, e.g., w o pedestrians, witnesses, other passengers, etc. W i z Step 2: Take photos of or write down the other person's driver's i license information and other vehicle's license plate number, 0 I' including state of registration. " " I Step 3: Take photos of or write down the other person's insurance card information,. Step 4: Take photos of the vehicles involved, damages and surrounding area of the accident, if it is safe to do so. Step 5: Call our AAA Claims Hotline at 800-672-5246 to report the loss. If necessary, we will arrange to have your vehicle towed. Our provider's tow trucks always display the AAA emblem. Do not admit responsibility for or discuss the circumstances of the accident p with anyone other than the police or an authorized Auto Club claims representative. Do not disclose your policy limits to anyone. I For questions or changes to your policy, call 1-877-422-2100, Monday through Friday from 7 a.m. to 9 p.m. or Saturday from 8 am. to 5 P.M. .._,_______________,.,.....----_____.._-____,_.__-_____.._..... - - - _........_____,._____....-----..----__-- _--__.._________,____-_-_. Evidence of financial responsibility shall at all times be carried in the vehicle. In addition, we suggest that each listed driver carry a card. Under California law, drivers and owners of a motor vehicle must be able to Call our AAA Claims show proof of financial responsibility at all times. Insurance information has already been submitted Hotline at 1-800-672-5246 directly to the DMV electronically, submit this document to DMV only if speclfica ly requested by DMV. These cards become invalid and should be destroyed on the expiration or termination date of the policy. r-- _-_----- ----------_ ,---- ---------------__-- _ ,-----------------..-------_--- ----- CaliforniaEvidence of InsuranceVEHICLES t ON POLICY " Interinsurance Exchange of the Automobile Club YEAR MAKE VEH I.D. M " r NAICM155 8 2018 INN 05010T JNIEV7AR6JM4322460591 m r Named Insured Policy Number: CAA130916694 JOSHUA SIEGERT i " r w r " x " o DRIVERS ON POLICY I d 0 SIEGERT, JOSHUA w 08/05/2024 Expiration Date: 08/05/2025 I SIEGERT, SHIHO w r This policy complies with Sections 16056 or 16500.5 of the California i Vehicle Code. Coverage subject to policy terms and limits. " r " a " ------_,,.»,----,.,»..---- _,-__,--_-- ----.----,----_--------w_e_-_..,-.....,-----........_..,.----------_-----_------------ IF YOU HAVE AN ACCIDENT CALL OUR 24/7 AAA CLAIMS HOTLINE 1-800-672-5246 k l y After an accident, exchange information with the other party and $ follow these 5 easy steps: I Step 1: Pull vehicle over to a safe place. Get the names, addresses, , pand phone numbers of all persons involved in the accident, e.g., ui I pedestrians, witnesses, other passengers, etc. W r = Step 2: Take photos of or write down the other person's driver's o p license information and other vehicle's license plate number, u. p including state of registration. u Step 3: Take photos of or write down the other person's insurance card information. I Step 4: Take photos of the vehicles involved, damages and surrounding area of the accident, if it is safe to do so. Step 5: Call our AAA Claims Hotline at 800-672-5246 to report the loss. If necessary, we will arrange to have your vehicle towed. Our provider's tow trucks always display the AAA emblem. Do not admit responsibility for or discuss the circumstances of the accident with anyone other than the police or an authorized Auto Club claims representative. Do not disclose your policy limits to anyone. I For questions or changes to your policy, call 1-877-422-2100, Monday through Friday from 7 a.m. to 9 p.m. or Saturday from 8 a.m. to 5 p.m. p_----„---------------------------------------,__------_.._...,__.»....-----____,---------__----_-_------_.....--------_. L ebP017 AA 8165 (10/24) 112224 CITY OF EL SEGUNDO WORKERS' COMPENSATION DECLARATION WARNING: FAILURE TO SECURE WORKERS' CO PENSATION 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: U I have and will maintain a cesttf Gate of consent of self -insure for workers' compensation, issued by the Director of Industrial Relations as provided for by LaborCode § 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 # di 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 persons 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 I must immediately comply with those provisions or the agreement will automatically become void. Signature of Applicant rows _ Date ° ' -20 -C74 Print Name � Agreement for: Dated: Reviewed by: