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PROOF OF INSURANCE (2011) CLOSEDDATE (MMIDDIYYYY)
ACOORV CERTIFICATE OF LIABILITY INSURANCE 3/17/2010
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 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
Britton - Gallagher and Associates, Inc.
6240 SOM Center Rd.
Cleveland OH 44139
NAIC #
INSURED
Fireworks & Stage F/X America, Inc. INSURERS:
P. 0. Box 488 INSURERC:
12650 Highway 67S Ste FA
Lakeside CA 92040 INSURER D:
INSURER E :
COVERAGES CERTIFICATE NUMBER: 1776691839 REVISION NUMBER:
ici iDr=n MAMFn AROVF FOR THE POLICY
THIS
PERIOD
WHICH
IS TO CERTIFY THAT THE POLICIES OF
INDICATED. NOTWITHSTANDING ANY
ALL THE CERTIFICATE MAY BE ISSUED
SONS AND CONDITIONS
INSURANCE
REQUIREMENT,
OA
PERTAIN,
LI51 tU Ot:LUVV nr+V c DCCiY !Q�w,
TERM OR CONDITION OF ANY
THE ICH POLICIES. IMITS SHOWN
CONTRACT
MAY POLICIES
BEEN
OR OTHER
REDUCEDIBY
DOCUMENT WITH RESPECT
PAID CLAIMS. SUBJECT
TO
INSR
LTR
TYPE OF INSURANCE
1,ENERAL LIABILITY
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE � OCCUR
ADDL
UBR
POLICY NUMBER
POLICY EFF
MMIDD/YYYY
1/11/2010
POLICY EXP
MM /DD/YYYY
1/11/2011
LIMITS
$ 1,000,000
A
1619322 -02
DAMAGE TO RENTED
DAMAGE TO
PREMISES Ea occurrence
$ 50,000
MED EXP (Any one person)
$
PERSONAL 8 ADV INJURY
$1, 000, 000
GENERAL AGGREGATE
$2,000,000
PRODUCTS - COMP /OPAGG
$2,000,000
B
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY X PRO- LOC
AUTOMOBILE LIABILITY
CA62656869
1/11/2010
1/11/2011
COMBINED SINGLE LIMIT
(Ea accident)
$1,000,000
BODILY INJURY (Per person)
$
X ANY AUTO
BODILY INJURY (Per accident)
$
ALL OWNED AUTOS
PROPERTY DAMAGE
(Per accident)
$
SCHEDULED AUTOS
X HIRED AUTOS
X NON -OWNED AUTOS
C
UMBRELLA LIAB
EXCESS LIAB
X
OCCUR
CLAIMS -MADE
EAU720120
1/11/2010
1/11/2011
EACH OCCURRENCE
$4,000,000
AGGREGATE
$4,000,000
DEDUCTIBLE
RETENTION $
WORKERS COMPENSATION
WC STATU- OTH-
TORY LIMIT I ER
E.L. EACH ACCIDENT
$
AND EMPLOYERS' LIABILITY
ANY PROPRIETOR /PARTNER /EXECUTIVE Y / N
OFFICERIMEMBER EXCLUDED?
(Mandatory In NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
NIA A
E.L. DISEASE - EA EMPLOYE
$
E.L. DISEASE - POLICY LIMIT $
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required)
Show Date: 7/4/2010 Show Time:apprx. 9:00pm Show Location: City Baseball Field
Additional Insured: City of E1 Segundo, City Baseball Field, E1 Segundo Fire Department City of El Segundo
See Attached...
to
City of E1 Segundo
Parks & Recreation Depar
401 Sheldon Street
El Segundo CA 90245 -3813
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED
IN ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
i
n ioaa_9nna OCnnin CORPORATION. All rights reserved.
ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD
POLICY NUMBER: 1619322 -02
COMMERCIAL GENERAL LIABILITY
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 Person or Organization:
City of El Segundo, Its officers, Officials, Employees, Agents, & Volunteers
401 Sheldon St.
El Segundo, CA 90245
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations
as applicable to this endorsement.)
WHO IS AN INSURED (Section il) is amended to include as an insured the person or organization shown in the
Schedule as an insured but only with respect to liability arising out of your operations or premises owned by or
rented to you .
CG 20 26 11 85 Copyright, Insurance Services Office, Inc., 1984 Page 1 of 1 O
ISSUE DATE: 06 -01 -2010
CITY OF EL SEGUNDO
401 SHELDON ST
EL SEGUNDO CA 90245 -4013
CERTHOLDER COPY
P.O. BOX 420807, SAN FRANCISCO,CA 94142 -0807
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
SO
GROUP
POLICY NUMBER: 0803053 -2010
CERTIFICATE ID: 91
CERTIFICATE EXPIRES: 06 -01 -2011
06 -01- 2010/06 -01 -2011
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.
V,rAaJ
tthor,zed Representative Interim President and CEO
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
FIREWORKS & STAGE FX AMERICA INC. (A CORP)
PO BOX 488
LAKESIDE CA 92040
(REV. 1-2010)
SD
M0408
PRINTED 05 -17 -2010;