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PROOF OF INSURANCE (2010) CLOSEDACORD,M CERTIFICATE OF LIABILITY INSURANCE ""ffiD1Y'"' ER Phone: 440 -248 -4711 Fax: 440 -248 -5406 2 26 2009 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Britton - Gallagher and Associates, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 6240 SOM Center Rd. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Cleveland OH 44139 ALTER THE COVERAGE AFFORDED SY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC 0 a+auREO 1/11/2009 Fireworks &Stage F/X America, Inc. INSURERA P. O. Box 4881 INSURER B: New__HgMrzhi re Insurance Co. 23841 12650 Highway 67S Ste FA INSURERC: ur Lakeside CA 92040 INSURER D: INSURER E: CATJFQafSCQ THE POLICIES OF INSURANCE LISTED BEIAW GAVE 13EEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. OTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICALTE 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. Im POLICYNUIM MLICYEPPECTIVE POLICY,1XNRAT1 a1 LMNTS A GMERAL LIABILITY COMMERCIAL GENERAL UAIULfTY 1619322 1/11/2009 1/11/2010 EACH OCCURRENCE s .S MADE ®OCCUR $ NEDEXP (Any oneperew) S PERSONAL3ADVINJURY $1,000,000 GENERAL AGGREGATE $ GEML AGGREGATE LANIT APPLIES PER: POLICY Y1 PRO- LOC PRODUCTS - COMPICPAGO S B LEUA9KJTY UTO CA62656868 1/11/2009 1/11/2010 OD�EO��L� (Eaeodwm) $1,000,000 FALLOWNEDAUTOS DULED AUTOS BODILY INJURY (P-P —) AUTOS WNWAUTOS BODILY INJURY S PROPERTY DAMAGE (Per eccide�) S .._. ....... ._._,.__ GARAGE LIABILITY ANY AUTO AUTO ONLY. EA ACCIDENT S OTHER 7HAN EA ACC AUTO ONLY: AGO $ S C EXCESSAlM BIALIABILITY OCCUR CLAIMS MADE SAU720120 1/11/2009 1/12/2010 EACHOCCURRENCE S4.00 .000 AGGREGATE ; s DEDUCTIBLE RETENTION S S s WORIfERS COMPENSATION AND EMPLOYERS' LIABILITY I WC STATU- H I E.L. EACH ACCIDENT S ANY PROPRIETORIPARTNERMYECUTNE OFFICER44EMBEREXCLUDED? E.L.DISEASE- EAEWLOYEE S Hyte,deeuibeuger SPECIAL PROVISION OTHER E.L. DISEASE - POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS VEHICLESI EXCLUSIONS ADDED By ENDORSEMENT I SPECIAL PROVISIONS how Date: 7/4/2009 Show Time:apprx. 9:00pm Show Location: City Baseball Field n theiralInsured: City tofaIII Segundo Parks and Recreation Department, its officers, agents and employees when acting CERTIFICATE HlL nFQ City of E1 Segundo Parks ✓« Recreation Department 401 Sheldon Street E1 Segundo CA 90245 -3813 ACORD 25 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORU TED REPRESENTATIVE by /15 /lldb`1 l5 :42 bl`l'JJUW3 /3 POUCY NUMBER: 1619, 3_ COIIAMERCIAL GENERAL UABIUiY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED -- DESIGNATED PERSON OR ORGANIZATION Tift endorsement moddes Insurance Wovidad under the foNowing: COMMERCIAL GENERAL LIABILITY COVERAGE PART, SCHEDULE Now of Person or Orgw*zoWn: City of El Segundo Parks and Recreation Department, its officers, agents and employees when acting In their offlcial Capacity as such. Show Date: 7/4/2009 Show Time:apprx. 9:00pm Show Location: City Baseball Field (If no entry appears above, infc=lion required to complete INt endorsoftw t wi be shown in the Decissations as applioabie to this endmoorrlent.) WHO 18 AN INSURED (Section Ul N amended to Include as an insured the person or orgenfzaft d v*m in the Schedule as on Insured but orgy YAM reaped to toad y arfshg out of your operatlons or pramisss owned by or IN to you CG 20 261185 Copyrfghk insurance Services Ofiice, Im, 1984 Pape 1 of 1 D rcuat nai nv FES -26 -2009 14:37 6199388273 97% P.03 CERTHOLDER COPY STATE P.O. BOX 420807, SAN FRANCISCO,CA 94142 -0807 COMPENSATION INSURANCE FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 06 -01 -2008 GROUP: POLICY NUMBER: 0803053 -2008 CERTIFICATE ID: 91 CERTIFICATE EXPIRES: 06-01 -2009 06- 01-2008/06 -01 -2009 CITY OF EL SEGUNDO 401 SHELDON ST EL SEGUNDO CA 90245 -4013 SD This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer. We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy. THORIZED REPRESENTATI PRESIDENT f EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 06 -01 -1995 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. EMPLOYER BOX 488 LAKESIDE CA 92040 M0408 (REV.2-05) PRINTED : 05 -16 -2008 SD STATE COMPENSATION INSURANCE FUND IN REPLY REFER T0: MARCH 20, 2008 Policy NOW: 803053 -07 L &H- 0903053 -07 CITY OF EL SEGUNDO 401 SHELDON ST EL SEGUNDO CA 90245 -4013 CERTIFICATE OF WORKERS' ----------------------- COMPENSATION INSURANCE CANCELLATION WITHDRAWAL NOTICE ------------------------ - - - - -- RE: CERTIFICATE DATED FEBRUARY 5, 2008 THE CANCELLATION HAS BEEN WITHDRAWN FOR THE WORKERS' COMPENSATION INSURANCE POLICY FOR THE EMPLOYER NAMED BELOW. THIS LETTER SUPERSEDES THE NOTICE OF CANCELLATION SENT TO YOU ON MARCH 17, 2008. THIS EMPLOYER'S WORKERS' COMPENSATION INSURANCE COVERAGE CONTINUED UNINTERRUPTED. POLICYHOLDER SERVICES SAN DIEGO DISTRICT OFFICE (858) 552 -7000 1275 Market Street • San Francisco, CA 94103— 1410 Mailing Address: P.O. Box 420807 • San Francisco, CA 94142 -0807 SCIF 19102 STATE COMPENSATION INSURANCE FUND IN REPLY REFER T0: MARCH 19, 2008 Policy NOW: 803053 -07 L &H- 0903053 -07 CITY OF EL SEGUNDO 401 SHELDON ST EL SEGUNDO CA 90245 -4013 CERTIFICATE OF WORKERS' ----------------------- COMPENSATION INSURANCE ---------------------- CANCELLATION NOTICE ------------- - - - - -- RE: CERTIFICATE DATED FEBRUARY 5, 2008 THE WORKERS' COMPENSATION INSURANCE POLICY FOR THE EMPLOYER NAMED BELOW HAS BEEN CANCELLED EFFECTIVE APRIL 22, 2008 AT 12 :01 A.M. IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, PLEASE CONTACT THE EMPLOYER NAMED BELOW EMPLOYER: I LAKESIDE, CA 92040 POLICY 0803053 -07 POLICYHOLDER SERVICES SAN DIEGO DISTRICT OFFICE (858) 552 -7000 1 275 Market Street • San Francisco, CA 94103— 1410 Mailing Address: P.O. Box 420807 • San Francisco, CA 94142 -0807 SCIF 19102 STATE COMPENSATION INSURANCE FUND JUNE 20, 2006 CITY OF EL SEGUNDO 401 SHELDON ST EL SEGUNDO CA 90245 -4013 CERTIFICATE OF WORKERS' ----------------------- COMPENSATION INSURANCE ---------------------- CANCELLATION NOTICE ------------- - - - - -- RE: CERTIFICATE DATED JUNE 14, 2006 IN REPLY REFER T0: THE WORKERS' COMPENSATION INSURANCE POLICY FOR THE EMPLOYER NAMED BELOW HAS BEEN CANCELLED EFFECTIVE JULY 24, 2006 AT 12:01 A.M. IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, PLEASE CONTACT THE EMPLOYER NAMED BELOW EMPLOYER: FIREWORKS AMERICA PO BOX 488 LAKESIDE, CA 92040 POLICY 0803053 -06 POLICYHOLDER SERVICES SAN DIEGO DISTRICT OFFICE (858) 552 -7000 1275 Market Street • San Francisco, CA 94103 -1410 Mailing Address: P.O. Box 420807 • San Francisco, CA 94142 -0807 SCIF 19102