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PROOF OF INSURANCE (2025) CLOSEDWCELSEG-01 DATE (MMIDDIYYYY) �~ 5/30/2025 CERTIFICATE OF LIABILITY INSURANCE 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:.....Ifmmthe 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 s this certificate does not confer rlglrots to mho certificate holder in lieu of such endorsement � wwww_�wwwwwwwwww � _ ..... CONTACT PRODUCER I I �_....� 714.975 896.._ Arc Nv E:t 7'1+t NFP PTope Casualty Services, Inc. 505 5550 Arc I ( 6 rty Pt10NE FAx 1551 North 7ustm Avenuer Suite 500 ws• m Santa Ana, CA 92705 rnre¢iwarvxccr n"znRDINr. COVERAGE NAIL p INSURED El Segundo Woman's Club PO Box 25 El Segundo, CA 90245 Ct Insurance Alliance of California Inc. COVERAGES TO CERTIFwICATE_NUMB R SUED TO THE INSURED REVISION NUMBER _ THIS O CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN IS D 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, F CLAIMS. iTSXCLIJI4N!9 AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN IwP LICv E BY PAIOD 1,,,,, ,,, ,,, -.yy LIMITS _ ADDL SUER F POLICY EXP TYPE OF INSURANCE POLICY NUMBER LkL21r0fi!!'!Yll. „ 1 A X COMMERCIAL GENERAL LIABILITY ErM1,Ctl^t OIww4 VJjt&tNP E S„ _. ��'�n�. OCCUR 2024-25959 8/1/2024 8/1/2025 DAMAGE TO RENTED 500,000 .... m CLAIMS -MADE X X .. f 20,000 ... ..______..._. ... MEP EXP IA0Y one Peix Xnl, d�� ,�......... ...'.... .. PERSONAL&ADVINJURY 1,000,000 --GEN I. AGGREGATE LIMIT APPLIES ,.,.,...... E � S GENERAL AGGREGATE. „�, 000 000 PER: LA .. 3 mti POLICY F ,,,J JECT LOC „PRCJOVCTS COMPAOP,AGG 5 tl0 0 �► AUTa _ _....... _ 00,000 _. m E LIABILITY INCI E LIMIT ... ;ornoeANY AUTO 2024-25959 8/1/2024 8/1/2025 BODILY INJURY.(Per perspn) OWSCHEDULED AUTNEDOS ONLY _ AUTOS BO�P�r"{b�^ DAMAGE I nib $ ����� �~ ��� . . . � era, e X H�RED X 1.N ll. WN a7 PROPeeldo�titi,..... ,cc A TOS ONLY A TO OLY ._. .. UMBRELLA LIAS OCCUR F.. CH OCCURRENCE S i EXCESS LIAB CLAIMS -MADE AGGREGATE .-.. j DED � RETENTION YIN $ S PRIETOR/PAR7NERlEXECmmmm .. ..-....--- � _......---- WORKERS COMPENSATIONIF AND EMPLOYERS' LIABIL nT' UTIVE E.L. EACH ACCIDENT OTl m WORKERS m,�..... .... ANY 4,1 1-gQ ERIMEMBER EXCLUDED? N I A anldatory In NH) EIf yes, describe under POLICY LIMIT 5 ..... g Directors S ORic rs OPERATIONS Below .._..... NFP0130789-07 1/5 2025 1/512 m E.L-DISEASE- 026 C7ccurence/Aggregate _ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS r VEMICLE$ (ACORD 101, Additional Remarks Schedule, may be attachedh.� Y ace ._ ...-_ ----- � XXX � if more space is required) Event. El Segundo Recreation & Parks 4th of July Celebration The City of El Segundo, its officers, officials, employees, agents, and volunteers is an additonal insured for General Liability per the attached Endorsement Form CG20261219 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN The City of El Segundo ACCORDANCE WITH THE POLICY PROVISIONS. 90245 El Segundo, CA 90245 _,_ .....�� _ _r.........._ �—.- ... AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) ©1988-2015 ACORD 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. 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. L_) 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 # l 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 immediately comply with those grovigions or the �ement will automatically become void. Signature of Applicant Print Name Agreement for: Dated. Reviewed by: Date