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PROOF OF INSURANCE (2026)FIZATORD-01 PAT ACORN` CERTIFICATE OF LIABILITY INSURANCE DATE 10128/2025 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 endorsement(s PRODUCER Alera Group Nevada 9555 Hillwood Drive Suite 140 Las Vegas, NV 89134 304-7801 INSURED I INSURER6 ........... .... ............... ...,,..... ._.,.._ -.. . ,.,.,..._._ _ ,.... Fraternal Order of Real Bearded Santas (FORBS) 23052 Alicia Pkwy H-255 INsuRER D Mission Viejo, CA 92692 INSURER E............. .........._ ..._.____ ............�... INSURER F : ........... ............... m ..__.... ..........�...._...... .......__ COVERAGES CERTIFICATE NUMBER:_.... _._._REVISION NUIVpJBgj R: 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, TYPE of INSURANCE POLICIES LIMITS SHOWN ...... _._.illtllt! REDUCED BY PAID CLAIMS. _. EXCLUSIONS AND CONDITIONSNOF Y SUCHBEEN A X COMMERCIAL GE LICY EFF POLICY EXP LIMITS INSR ADDLSUER NUMBER PO, 1,000 O00 .... ..�. � Itl -- EACH OCCURRENCE CLAIMS -MADE X OCCUR PHPK2600535-013 OPT 1 10/1/2025 10/112026 RENTED100 000 - __ MED EXP iAnv one persons „,); ry . ...I. 000 RY 000 ., ,.. � .. PRODUCTS I� ADV INJU ...^. �t".r.EN Ada�„REGATELIMIT APPLIES PER: „ENERAL.A(,aGREGAT,E $ _ POLICY � . ,I GT LOG PRODUCTS..' COMP/OP AGG $ ......... 2 000 000 X OTHER c Per Member $ COMBINED SINGLE LIMIT mp!ovi"u. ANY AUTO 111 $ $ AU OWNED MOBILE LIABILITY SCHEDULED �E,l7DILY INJURY�,Per person] AUTOS ONLY AUTOS ,BODILY INJURY (,Per accident) I $ f ...,.,.. AONLY NOW-yVWtrdE`ILy P'RC"NN'F9 @"Y DAMAC'sD ....... Akk1'WPNI.:Y' ..I.Fur,ayrcg�CprtC).. ..- _. $ .... L_C SS LIABIAB OCCUR MADE ,...., _,_ ......... ... EACHAGGOCCURRENCE UMBRELLA _ T DIED i....... RETENTION ........_..__ .. .. ,... 1 $ ... D-, TION $ STAT�JE I $ ......_....__...._..... __ ....... ........ I .._ PER OTH WORKERS COMPENSATION Y TE E AND EMPLOYERS' LIABILITY 1 N - ANY PROPRIETOR/PARTNER/EXECUTIVE E L EACH ACCIDENT 11"I"tER/MEMBER EXCLUDED? NIA f t#4iar Zory in NH) _. El DISEASE E..A EMPLOYEE IF yes, describe under 1- I+r- DESCRIPTION OF OPER.L ATIONS below 9 EDISEASE - POLICY LIMIT ! $ DESCRIPTION OF OPERATIONS I LOCATIONS / VEHtCLIES ¢ACORD 101, Additional Remarks Schedule, maybe attached If more Sgace is required) Coverage includes ""Abuse 8: Mol'estatic with llmit,s 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 Andrew 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 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of El Segundo ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street El Segundo, CA 90245' AUTHORIZED REPRESENTATIVE Atz 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. affirm under penalty of perjury under the laws of California one of the following declarations: L_) 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 perft employ any person in any m agree that, if I should b a immediately comply with ho Signature of Applicant Print Name 0d[EWJJ,'U- E Agreement for: Dated; Reviewed by: Policy Number Expiration Date Phone # ce 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 Oject to the workers' compensation provisions of Labor Code § 3700 1 must /isions or the agreement will automatically become void. Date 10/23/24