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PROOF OF INSURANCE (2026)C40R "� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDNYYY) il%� 1 11/26/2025 CERTIFICATE DOES NOT AFFIRMATIVE LY 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: l t e certificate holder is an ADD( ZONAL INSURED, the po lcy(ies) must have AtUTIONAL 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($). PRODUCER K&K Insurance Group, Inc. P.O. Box 2338 Fort Wayne, IN 46801-2338 MM — Bands & Performing Groups 800 328-2317 entertainers@kandkinsurance.com 260-459-5502 CUSTOMER ID: ... .,..............._........ -._. _... ...... INSURERS) AFFORDING COVERAGE NAIC # ................................................. �..,..- ................. INSURED . ......_._... INSURER A: Markel Insurance Company mpany ...................... 38970 ......... Haile Blackman INSURER B: DBA: Upstream Music P ..... ........... ........ INSURER C: 245 S Allen Ave Ste 1 - •- Pasadena, CA 91106 INSURER D: A Member of the Sports, Leisure & Entertainment RPG INSURER E: -_........,-..,� ....._.............. ( INSURER........._.. .....•._...........,... F: rntiGoer-f=c CFRTIFICATF N11MRFR- Wn4014901 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. lNSR ADDL S LTR TYPE OF INSURANCE WSD WVD POLICY NUMBER EF POLICY (MM/DD MMIDD/YY_YY LIMITS (01/10/2026 A X COMMERCIAL GENERAL LIABILITY X Ml RP00000000352500 01/10/20022b-°f EACH OCCURRENCE $1,000 000 CLAIMS- MADEOCCUR . _.. . . .,. m,. ..... _.. 12:01 AM EDT 12:01 AM P�'�"�ITMiSESiErM�Ycr.�arcatrnce� $1,000000 MED EXP (Any one person) Excluded PERSONAL mm....._°°° &ADVINJURY Excluded GENERAL AGGREGATE $5,000,000 .......' ................ .GEN'LAGGREGATE LIMIT APPLIES PER: ...._ ___......._.. .... ...�..........�...�° PRODUCTS COMP/OPAGG $1,000,000 _.. .......... r....... POLICY PRO- LOG ._............. _..............-. PROFESSIONAL LIABILITY LO I6 5iiri 7F1_1­0"�°. """ ......_. ....._ $1, 000,000 OTHER:, PARTICIPANTS COMBINED SINGLE LIMIT.. AUTOMOBILE LIABILITY {Ea _ddent) ANY AUTO BODILY INJURY (Per person) IT OWNED AUTOS" SCHEDULED BODILY INJURY (Per accident) - ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY ..m NOT PROVIDED WHILE IN HAWAII UMBRELLA LIAB .00CUR (EACH OCCURRENCE EXCESS LIAR CLAIMS -MADE AGGREGATE ... ................. _. DED RETENTION WORKERS COMPENSATION AND N/A OTHER STATUTE EMPLOYERS' LIABILITY _..... ANY PROPRIETOR/PARTNER/ YIN E..L. EACH ACCIDENT ........_.. ...,- ........ _........ EXECUTIVE OFFICER/MEMBER EL. DISEASE -EA EMPLOYEE EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION EL DISEASE -POLICY LIMIT OF OPERATIONS below''. A MEDICAL PAYMENTS FOR PARTICIPANTS MlRPG0000000352500 01/10/2025 01/10/2026 PRIMARY MEDICAL $5,000 12:01 AM EDT 12:01 AM _ _........._...,_ ....... EXCESS MEDICAL DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Type of Group: Non -touring bands (tribute, wedding,. garage); Music Genre: Ethnic/world, Folk; Type of Venue: Auditoriums, Outdoor venues, Reception halls The certificate holder is added as an additional insured, but only for liability caused, in whole or in part, by the acts or omissions of the named insured. 1.IM "I.I Nr'1'4xA I tFIULUtK I lwwv ?City of El Segundo, its elected and appointed officials, employees, SHOULD' ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE and volunteers THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. El Segundo, CA 90245 AUTHORIZED REPRESENTATIVE (Owner, manager or lessor of a facility where the insured performs) Coverage is only extended to U.S. events and activities. " NOTICE TO TEXAS INSUREDS: The Insurer for the purchasing group may not be subject to all the insurance laws and regulations of the State of Texas ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: MlRPG0000000352500 COMMERCIAL GENERAL LIABILITY CG 20 26 04 13 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 PART SCHEDULE Name Of Additional Insured Persons Or Organization(s) ?City of El Segundo, its elected and appointed officials, employees, and volunteers 350 Main Street El Segundo, CA 90245 Named Insured: Haile Blackman DBA: Upstream Music Information re uired to complete this Schedule, if not shown above, will be shown in the Declarations. 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, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: 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. 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. CG 20 26 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1 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. U 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 ZII certify that, in the performance of the employ any person in any manner so as to agree that, if I should becorn su °ect to immediately comply with thpr ions 01 Signature of Appli nt Print Name N Agreement for: Dated: Reviewed by: Policy Number Expiration Date Phone # k set forth in the agreement with the City of El Segundo, I will not ome subject to the workers' compensation laws of California, and Yorkers' compensation provisions of Labor Code § 3700 1 must agreement will automatically become void. Date !I 2G Zo25