PROOF OF INSURANCE (2025) CLOSEDACC CERTIFICATE OF LIABILITY INSURANCE DATE`MM/DDnYYY'
k _ 04/17/2025
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
this certificate does not confer rights to the certificate holder in lieu of such endorsements .
PRODUCER 'CONTACT Will Maddux
NAME ....... .. ... ., ,
PHONE. .
East Main Street Insurance Services, Inc. (MA N% )) (530 477 6521 ; mI 1
Will Maddux ADDRI�SS info(heeventhelper,com
PO BOX 1298 INSURERS) AFFORDING COVE VERAGE NAIC#
Y R A Company 35378
111111111
Grass Valle � CA 95945 INsuREEvanston Insurance C ee m
INSURED INSURER B
Beach Print Holdings, LLC
c/o Kimarie Hunt
INSURERD:
-.,
531 Main St, #1116
INSURER E ...�..
„
El Segundo CA 90245
INSURERF.
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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.
LICY EFF
...._M/f-1D/YY
IL7R , TYPE OF INSURANCE e.....ALr�dSL«UFIjF POLICY NUMBERMPpOJbwPDDryYYY POLICY EXP LIMITS
i/'4.COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE j $ 1,000,000
.... t _
CLAIMS -MADE ®OCCUR {GJAfi�1JCGF'�'(t'd
Rf Nt-6 1 000 000
F NRgMISES tolherthanfGrel $,,. -_.
H
Host LlgUor Llablllty
I MED EXP (Any one person) $ 5,000
... -...
--------
---- ...
A Retail LI uorr Liiability Y
N 3DS5476-M4889725 05/03/2025 05/04/2025 P INJURY 1 $ 1,000,000
12:01 AM 12:01 AM GERSONAL GADV
ENERAL AGGREGATE $ 2,000,000
GEN L AGGREGATE LIMIT APPLIES PER:
A
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i
2,000,000
POLICYPRO LOC
„IA:.C.T
P Acc $
,,.,RODUCTS-COMP/OPeeeeeeeee
OTHER '
Deductible $ 1,000
' AUTOMOBILE LIABILITY
? COMTIINE'DSIN6.�LEi„IMI:"P $-
tEaapp'lognglw....... _,,,
ANY AUTO
!BODILY INJURY (Per person) 1 $...
- OWNED SCHEDULED
INJURY (Per accident) � $
AUTOS ONLY AUTOS
HIRED NON -OWNED
OERTYDAMAGE $
AUTOS Ij AUTOS ONLY
1
.� I
E (>?'+wayr.:,ua9entl,) ..... ..... ..,�.... ....... _.
$
UMBRELLA LIAB OCCUR
LEACH OCCURRENCE __ $
EXCESS LIAB I CLAIMS MADE
AGGREGATE $
.. .. ,,,,...- P ,� ...
,,,,,, ,,,,,, ,, , _._
DED RETENTION $
I
$
WORKERS COMPENSATION
j rH PER O
STATUTE ER
AND EMPLOYERS' LIABILITY Y / N
ANYPROPRIETOR/PARTNER/EXECUTIVE
- --- .. ...
E,L EACH ACCIDENT
........
Is
OFFICER/MEMBER EXCLUDED? [ N / A
(Mandatory in NH)
E DISEASE EA EMPLO- YEE
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$
If yes, describe under 1
L
j $
%DESCRIPTION OF OPERATIONS below i
E.L. DISEASE-POLIIMIT
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DESCRIPTION OF OPERATIONS /LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required)
Certificate holder listed below is named as additional insured per attached MEGL 2217 01 19. Attendance: 100, Event Type: Vendor at Event.
CERTIFICATE HOLDER L;A IL;t1-LAI IUIV
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
City of El Segundo AUTHORIZED REPRESENTATIVE«
350 Main St ��V
ElSegundo CA 90245
v 1 VStf-ZU10 AGUFfu L UtJrVMA I tU1111. NB ngntb rebel Veu.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
COMMERCIAL GENERAL LIABILITY
POLICY NUMBER: 3DS5476-M4889725
IRKEV EVANSTON INSURANCE COMPANY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE FORM
SCHEDULE
Name Of Additional Insured Person(s) Or Organization(s):
City of El Segundo
350 Main St
El Segundo, CA 90245
A. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or
organization(s) shown in the Schedule of this endorsement, but only with respect to liability for
"bodily injury", "property damage" or "personal and advertising injury' caused, in whole or in part,
by the acts or omissions of any insured listed under Paragraph 1. or 2. of Section II — Who Is An
Insured:
1. In the performance of your ongoing operations; or
2. In connection with your premises owned by or rented to you.
However:
1. The insurance afforded to such additional insured only applies to the extent permitted by law; and
2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to
such additional insured will not be broader than that which you are required by the contract or agreement to
provide for such additional insured.
MEGL 2217 0119 Includes copyrighted material of Insurance Services Office, Inc., Page 1 of 2
with its permission.
B. With respect to the insurance afforded to these additional insureds, the following is added to
Section III — Limits Of Insurance:
If coverage provided to the additional insured is required by a contract or agreement, the most we
will pay on behalf of the additional insured is the amount of insurance:
1. Required by the contract or agreement; or
2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less.
This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations.
All other terms and conditions remain unchanged.
MEGL 2217 0119 Includes copyrighted material of Insurance Services Office, Inc., Page 2 of 2
with its permission.
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
Name of Agent
Policy Number Expiration Date
Phone #
certify that, in the performance of the work set forth in the agreement with the City of El Segundo, I will not
e ploy any person in and manner o as to become subject to the workers' compensation laws of California, and
agree that; if I should tecom` sect to the worka rs' co pensation provisions of Labor Code § 3700 I must
immediately comply Witt those f 4sions Pr the a e ment IR automatically become void, l �}
w .�,.
Signature of Applicant � Date,
Print Name
Agreement for:
Dated-,
Reviewed by: