PROOF OF INSURANCE (2026)a DATE (MMIDDIYYYY)
CAOR " CERTIFICATE OF LIABILITY INSURANCE
12I01 I2025
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 CONTACT Sherry Selleck CIC
NAME:
Church & Casualty Ins Agency Inc PHONE (800) 995-7525 A No (800) 995-7521
ft& No. Exth
38 Executive Park Suite 200Apr
aw,crz. Sherry@ccia.com
INSURER(S) AFFORDING COVERAGE NAIC #
Irvine CA 92614 INSURERA: Philadelphia Insurance Companies PHLY
...... w
INSURED INSURER B :
Jewish Community Center of the South Bay, DBA: The Academy of Arts INSURER C :
2108 Vail Ave INSURER D :
INSURER E :
Redondo Beach CA 90278-2518 INSURER F
rnWI=0Ancc C-ERTIF!C-ATE NtIMRFP- CL25112425790 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAYBE 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 .........ADDLSUSR OLICY' EFF POLICY EXP
''. LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER YYV (MM/DD/V MM/UD/YYYY LIMITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE
$ 1,000,000
..b�Fr RL "t"� _
_ 100 000
CLAIMS -MADE Fx_] OCCUR PREMISES Eaoc51Lr rnca
$
MED EXP (Any one person)
$ 5,000
A Y PHPK2728628-000 11/14/2025 11/14/2026 PERSONAL &ADV INJURY
$ 1,000,000
QE.NLAG:GREGATE'LIMITAPPLIESPER: �, GENERAL AGGREGATE
$ 3,000,000
❑PRO. �
POLICY JE&:.0. LOC PRODUCTS - COMP/OP AGG
I
$ 3,000,000
S
OTHER:
AUTOMOBILE LIABILITY L,OJUIBINED SINGLt;.. LIMIT
Ea aorrdczrtit.
$
ANYAUTO BODILY INJURY (Per person)
$
OWNED SCHEDULED BODILY INJURY (Per accident)
S
AUTOS ONLY AUTOS
NON-OWNEDDAMAGE
$
AHIRED UTOS ONLY ONLY 1°PROPERTY
k' ar acEidenO ., .
W
UMBRELLA LIAB1-1 OCCUR EACH OCCURRENCE _
$
EXCESS LIAB CLAIMS -MADE AGGREGATE
,.--...'_DED
,$
RETENTION $
$
WORKERS COMPENSATION PER OTH-
STATUTE. ER
AND EMPLOYERS'LIABILITY YIN
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT
$
N I A
OFFICER/MEMBER EXCLUDED? El
(Mandatory in NH) E.L. DISEASE - EA EMPLOYEE
$
If yes, describe under
DESCRIPTION OF OPERATIONS below E.L DISEASE - POLICY LIMIT
.. ...... ......._ ..........
$
.............
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
For General Liability Only. Evidence of insurance for use of premises for Joy Around the World singing event located at El Segundo City Hall, 350 Main St,
El Segundo, CA 90245 on December 2, 2025. The City of El Segundo, its elected and appointed officials, employees, and volunteers are named additional
insured only with respect to the activities of the Named Insured on the above described premises. All activities/operations not speclfCally run or conducted
by the Named Insured are excluded. Refer to attached PI-RO-012 (10/16) General Liability Deluxe Endorsement. Any insurance afforded by this policy shall
be Primary and Non -Contributory. 30-Day Notice of Cancellation applies.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of El Segundo Dept of Recreation, Parks & Library
ACCORDANCE WITH THE POLICY PROVISIONS.
401 Sheldon Street
AUTHORIZED REPRESENTATIVE
ElSegundo CA 90245
V IUtR1-LUIb AL UKLP L UKrVKAI IUIY. All rI(grtt5 RMU1 VVU.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
Philadelphia Indemnity Insurance Company
PI-RO-012 (10/16)
THIS ENDORSEMENT CHANGES THE POLICY., PLEASE READ IT CAREFULLY.
GENERAL LIABILITY DELUXE ENDORSEMENT:
RELIGIOUS ORGANIZATION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE
It is understood and agreed that the following extensions only apply in the event that no other specific
coverage for the indicated loss exposure are provided under this policy. If such specific coverage
applies, the terms, conditions and limits of that coverage are the sole and exclusive coverage applicable
under this policy, unless otherwise noted on this endorsement. The following is a summary of the Limits
of Insurance and additional coverage provided by this endorsement. For complete details on specific
coverages, consult the policy contract wording.
........
Coverage Applicable Limit of Insurance Page #
Damage to Premises Rented to You
$300,000
2
Expected or Intended Injury -Property Damage
included
2
.............. ..............
Non -Owned Watercraft
Less than 58 feet
2
Medical Payments
.....
$15,000
2
Medical Payments — Extended Reporting Period
3 years
3
Athletic Activities
Included for Non -Organized
3
Activities
Covered Injury Reimbursement
Included
3
_................
Wage Loss
included
3
wwwwww.�
Supplementary Payments — Bail Bonds
$2,500
4
........
Supplementary Payment— Loss of Earnings
$500 per day
4
Employee Indemnification Defense Coverage for Employee
$25,000
4
Additional Insured -Medical Directors and Administrators
Included
4
W
Additional Insured — Managers and Supervisors
included
4
Additional Insured -Organization and Subsidiary
Included
4
Additional Insured — Funding Source
Included
4
Additional Insured — Managers or Lessors of Premises
........................................
included
4
Duties in the Event of Occurrence, Claim or Suit
Included
5
Unintentional Failure to Disclose Hazards _
Included
5
Liberalization
Included
5
_._._
Bodily Injury— includes Mental Anguish
........
Included
......
5
Personal and Advertising Injury — includes Abuse of
Included
5
Process, Discrimination
PI-RO-012 (10/16) Page 1 of 6
Includes copyrighted material of Insurance Services Office, Inc., with its permission.
Philadelphia Indemnity Insurance Company
W-M!EMM70�-
PI-RO-012 (10/16)
If damage by fire to premises rented to you is not otherwise excluded from this Coverage Part, the
word "fire" is changed to "fire, lightning, explosion, smoke, or leakage from automatic fire protective
systems" where it appears in:
1. The last paragraph of SECTION I - COVERAGES. COVERAGE A BODILY INJURY AND
PROPERTY DAMAGE LIABILITY after the Exclusions;
2. Paragraph 6 of SECTION III - LIMITS OF INSURANCE;
3. Paragraph b.(1)(b) of 4. Other Insurance in SECTION IV - COMMERCIAL GENERAL LIABILITY
CONDITIONS; and
4. Paragraph 9.a. "Insured contract' in SECTION V - DEFINITIONS.
The Damage To Premises Rented To You Limit section of the Declarations is amended to the greater
of:
1.) $300,000; or
2.) The amount shown in the Declarations as the Damage to Premises Rented to
You Limit.
This is the most we will pay for all damage proximately caused by the same event, whether such
damage results from fire, lightning, explosion, smoke, or leaks from automatic fire protective systems
or any combination thereof.
B. Extended "Pro ert Damage"'
SECTION I - COVERAGES. COVERAGE A, COVERAGE A BODILY INJURY AND PROPERTY
DAMAGE LIABILITY 2. Exclusions a. is deleted and replaced by the following:
a. Expected or Intended Injury
"Bodily Injury" or "Property Damage" expected or intended from the standpoint of the insured.
This exclusion does not apply to "bodily injury' or "property damage" resulting from the use of
reasonable force to protect persons or property.
C. Non -Owned Watercraft
SECTION I - COVERAGES. COVERAGE A, COVERAGE A BODILY INJURY AND PROPERTY
DAMAGE LIABILITY 2. Exclusions, paragraph g. (2) is amended to read as follows:
(2) A watercraft you do not own that is:
(a) Less than 58 feet long; and
(b) Not being used to carry persons or property for a charge;
This provision applies to any person, who with your consent, either uses or is responsible for the
use of a watercraft. This insurance is excess over any other valid and collectible insurance
available to the insured whether primary, excess or contingent.
D. Medical Payments - Limit Increased to $15,000, Extended Reporting Period
If COVERAGE C MEDICAL PAYMENTS is not otherwise excluded from this Coverage Part:
1. The Medical Expense Limit is changed subject to all of the terms of SECTION III -LIMITS OF
INSURANCE to the greater of:
a. $15,000; or
PI-RO-012 (10/16) Page 2 of 6
Includes copyrighted material of Insurance Services Office, Inc., with its permission.
Philadelphia Indemnity Insurance Company
PI-RO-012 (10/16)
b. The Medical Expense Limit shown in the Declarations of this Coverage Part.
COVERAGE C MEDICAL PAYMENTS. 1. Insuring Agreement a., provided that: (2) is
amended to read:
(2) The expenses are incurred and reported to us within three years of the date of the
accident;
E. Athletic Activities
COVERAGE C MEDICAL PAYMENTS. 2. Exclusions. e. Athletic Activities is deleted and
replaced with the following:
e. Athletic Activities -to a person injured while taking part in athletics.
E. Covered Injua Reimbursement
When a covered injury to a claimant results in loss of life within one year from the date of the
accident, we will pay $5,000 to the following:
1. the parent or guardian if the deceased was a minor;
2. the surviving spouse, if any; or
3. a person authorized by law or legally entitled to receive such payment.
MUMNIFM
We will pay "wage loss" as described below to an injured person if the injured person is also eligible
for payment under COVERAGE C MEDICAL PAYMENTS, subject to the additional terms below.
a. Exclusions
1. arising out of any actual or alleged act of "sexual misconduct or sexual molestation";
including damages on account of any negligent hiring or transfer of, failure to supervise or
failure to dismiss any employee or volunteer worker alleged to have committed any act of
"sexual misconduct or sexual molestation".
2. for any "wage loss" that is not documented or which is speculative in nature.
3. for time away from work by an injured person unless required by a physician, or for time
away from work after a physician has given approval for the injured person to return to work,
b. Limit of Insurance
1. We will pay two-thirds of the "wage loss" sustained by an injured person. In the event that
another policy, program or plan pays a portion of the "wage loss" but less than two-thirds of
the "wage loss" then we will pay the difference between that portion and two-thirds of the
"wage loss".
2. The most we will pay under this coverage extension is $5,000.
c. Conditions
1. Proof of "wage loss" must be provided in writing by the employer of the person sustaining the
"wage loss". If a person to whom coverage applies under this extension is self-employed,
then such person must provide tax returns and other necessary records to document their
"wage loss".
d. Definition
1. "Wage loss" means loss of actual gross income, but only to the extent that such income was
being paid on the date that "bodily injury/' caused by an accident occurred. "Wage loss"
does not include potential income that may have been received from overtime hours, on -call
pay, or similar types of compensation. "Wage loss" also does not include compensation for
PI-RO-012 (10/16) Page 3 of 6
Includes copyrighted material of Insurance Services Office, Inc., with its permission.
Philadelphia Indemnity Insurance Company
PI-RO-012 (10/16)
paid sick leave, short-term disability days, long-term disability days, or family leave that was
used as a result of the "bodily injury".
K Supplementani, Payments
In the SUPPLEMENTARY PAYMENTS - COVERAGE A AND B provision:
1. The limit for the cost of bail bonds is changed from $250 to $2,500; and
2. The limit for loss of earnings is changed from $250 a day to $500 a day..
I. Em Io ee Indemnification Defense Covera e
Under SUPPLEMENTARY PAYMENTS - COVERAGES A AND B the following is added:
3. We will pay, on your behalf, defense costs incurred by an "employee" in a criminal proceeding.
The most we will pay for any "employee" who is alleged to be directly involved in a criminal
proceeding is $25,000 regardless of the numbers of employees, claims or "suits" brought or
persons or organizations making claims or bringing "suits".
J. SECTION II - WHO IS AN INSURED is amended as follows:
1. If coverage for newly acquired or formed organizations is not otherwise excluded from this
Coverage part, paragraph 3.a is changed to read:
a. Coverage under this provision is afforded until the end of the policy period.
2. Each of the following is also an insured:
a. Medical Directors and Administrators - Your medical directors and administrators, but only
while acting within the scope of and during the course of their duties as such. Such duties do
not include the furnishing or failure to furnish professional services of any physician or
psychiatrist in the treatment of a patient.
b. Managers and Supervisors - If you are an organization other than a partnership or joint
venture, your managers and supervisors are also insureds, but only with respect to their duties
as your managers and supervisors.
c. Organization and Subsidiary - Any organization and subsidiary thereof which you control and
actively manage on the effective date of this Coverage part. However, coverage does not
apply to any organization or subsidiary not named in the Declarations as Named Insured, if they
are also insured under another similar policy, but for its termination or the exhaustion of its limits
of insurance.
d. Funding Source - Any person or organization with respect to their liability arising out of:
1) Their financial control of you; or
2) Premises they own, maintain or control while you lease or occupy these premises.
This insurance does not apply to structural alterations, new construction and demolition
operations performed by or for that person or organization.
e. Managers or Lessors of Premises - Any person or organization with respect to their liability
arising out of the ownership, maintenance or use of that part of the premises leased to you
subject to the following additional exclusions:
This insurance does not apply to:
PI-RO-012 (10/16) Page 4 of 6
Includes copyrighted material of Insurance Services Office, Inc., with its permission.
Philadelphia Indemnity Insurance Company
PI-RO-012 (10/16)
1) Any `occurrence" which takes place after you cease to be a tenant in that premises.
2) Structural alterations, new construction or demolition operations performed by or on behalf
of that person or organization.
K. Duties in the Event of Occurrence Claim or Suit
1. The requirement in Condition 2. a. of SECTION IV - COMMERCIAL GENERAL LIABILITY
CONDITIONS that you must see to it that we are notified as soon as practicable of an 'occurrence"
or an offense, applies only when the `occurrence" or offense is known to:
a. You, if you are an individual;
b. A partner, if you are a partnership; or
c. An executive officer or insurance manager, if you are a corporation.
2. The requirement in Condition 2.b. that you must see to it that we receive notice of a claim or "suit'
as soon as practicable will not be considered breached unless the breach occurs after such claim
or "suit' is known to:
a. You, if you are an individual;
b. A partner, if you are a partnership; or
c. An executive officer or insurance manager, if you are a corporation.
L. Unintentional Failure To Disclose Hazards
It is agreed that, based on our reliance on your representations as to existing hazards, if you should
unintentionally fail to disclose all such hazards prior to the beginning of the policy period of this
Coverage Part, we shall not deny coverage under this Coverage Part because of such failure.
M. Liberalization
If we revise this endorsement to provide more coverage without additional premium charge, we will
automatically provide the additional coverage to all endorsement holders as of the day the revision is
effective in your state.
SECTION V - DEFINITIONS
N. Bodily Injury - Mental Anguish
The definition of 3. "Bodily Injury' is changed to read:
"Bodily Injury":
a. Means bodily injury, sickness or disease sustained by a person, and includes mental anguish
resulting from any of these; and
b. Except for mental anguish, includes death resulting from the foregoing (item a. above) at any
time.
O. Personal and Advertising Iniu — Abuse of Process Discrimination
If COVERAGE B PERSONAL AND ADVERTISING INJURY LIABILITY COVERAGE is not otherwise
excluded from this Coverage Part, the definition of "Personal and Advertising Injury" is amended as
follows:
1. Item 14 b. is revised to read:
a. Malicious prosecution or abuse of process:
PI-RO-012 (10/16) Page 5 of 6
Includes copyrighted material of Insurance Services Office, Inc., with its permission,.
Philadelphia Indemnity Insurance Company
2. Adding the following:
PI-RO-012 (10/16)
"Personal and advertising injury"also means discrimination based on race, color, religion, sex,
age or national origin, except when:
1. Done intentionally by or at the direction of, or with the knowledge or consent of:
a. Any insured; or
b. Any executive officer, director, stockholder, partner or member of the insured; or
2. Directly or indirectly related to the employment, former or prospective employment,
termination of employment, or application for employment of any person or persons by an
insured; or
3. Directly or indirectly related to the sale, rental, lease or sublease or prospective sales, rental,
lease or sub -lease of any room, dwelling or premises by or at the direction of any insured; or
4. Insurance for such discrimination is prohibited by or held in violation of law, public policy,
legislation, court decision or administrative ruling.
The above does not apply to fines or penalties imposed because of discrimination.
b. "Personal and Advertising Injury" does not mean discrimination based on gender identity,
gender expression or sexual orientation.
PI-RO-012 (10/16) Page 6 of 6
Includes copyrighted material of Insurance Services Office, Inc., 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 Policy Number Expiration Date
Name of Agent Phone #
( J) 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
immediately Signature Ap l comply
r the a reement will automatically became void, _
cornp y with those provisions � �
Date
Print Name �0 t i �,
Agreement for:
Dated,
Reviewed by.: