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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;