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PROOF OF INSURANCE (2015) CLOSEDA 111 1 CC>Ra CERTIFICATE OF LIABILITY (MMIDDNY O 4YY) 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 NAME: eT Stephanie Weiss FAX Minneapolis, MN 155428 EFMAIL x49, 715-246-8908 @ p y noeagency com •t i - - - 7225 Northland Dr N #300 iA N�k� rs. 1nst�ra N 715-246-4257 p ADORES 5 oola., Attn: Colleen Johnson INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: Lexington Insurance Company 19437 INSURED Performers of the U.S. and Club Members _INSURER B., Phone: 715 - 246 -8908 Fax: 715 - 246 -4257 INSURER C: Attn: Stephanie Weiss INSURER D PO Box 24 New Richmond, WI 54017 INSURER E: INSURER F : COVERAGES CERTIFICATE NUMBER: 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., ....UMBER 1111 1111...,. .. t _ "'_____...11 _____11. ____. -------------- ...___._.._...._.... ----- 9UI'§TI 1111 IN §R Y Mro —MM TYPE OF INSURANCE... POLICY PD YY LIMITS LTR N MM90DY GENERAL LIABILITY EACH OCCURRENCE $ 3,000,000' X COMMERCIAL GENERAL LIABILITY PRMIS,ESE,¢c Fsnn $ 300,000 CLAIMS -MADE I'• i, OCCUR MEDEXP(Anyone person) . - - $ ................ mmmm5,000 A X LX9776 08/04 ......HLX0404 X X 021396070 04/25/14 04/25/15 PERSONAL & ADV INJURY $ 3,0001020- X GENERAL AGGREGATE$ - 5.000,000. .......... ......................5,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS COMP /OP AGG $ X POLICY ' PRO- LOC 1111. $ AUTOMOBILE . 1111.. LIABILITY COMBINED SINGLE :. LIMIT IWI Taa.4,4r%si1) $ ANY AUTO BODILY INJURY (Per person) $ 1111 ALL OWNED SCHEDULED -� ....4 BODILY INJURY (Per accident) . -- •......., ,... ............. $ AUTOS AUTOS PROPERTY DAMAG $ NON -OWNED HIRED AUTOS AUTOS Per accident UMBRELLA LIAB OCCUR ''. EACH OCCURRENCE $ ''.. AGGREGATE $ EXCESS LIAB CLAIMS -MADE -1 DE RETENTION $ WORKERS COMPENSATION WC STATU 0TH - AND EMPLOYERS' LIABILITY Y / N - TDWR�y.i�J!'lUf5 511 ANY PROPRIETOR /PARTNER /EXECUTIVE E L EACH ACCIDENT $ EXCLUDED N / A (Mandatory In NH) ) E L. DISEASE - EA EMPLOYEE $ lfs, describe under D g CRIPTION OF OPERAT'iONS below EL DISEASE - POLICY LIMIT '... $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) PERFORMER IS A NAMED INSURED AS A MEMBER OF PERFORMERS OF THE U.S. (FORM LEXD00O21 LX0404): Eric R Greenberg dba Liberty City Additional Insured: The City of El Segundo, its officers, officials, employees, agents and certified volunteers are named as additional insured, but only insofar as the operations under this contract are concerned. Fax: 818 - 344 -6108 Email: Iibertycityeric @aol.com Attn: Jessie LeMay CERTIFICATE HOLDER CANCELLATION City of El Segundo 350 Main St. Room 5 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE El Segundo, CA 90245 -38' THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE W_94; 94; -r' \W IV00 -AV IV M%,%JRL! <rVRrVIVY I IVIV. M11 Ilu II Lb ICSCIVUU. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 021396070 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - (FORM B) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART. SCHEDULE Name of Person or Organization: The City of El Segundo, its officers, officials, employees, agents and certified. (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 II) is amended to include as an insured the person or organization shown in the Schedule, but only with respect to liability arising out of "your work" for that insured by or for you. This insurance will be deemed "primary" such that any other insurance that may be carried by City of El Segundo will be excess thereto. This insurance will be on an "occurrence ", not a "claims made" basis or equivalent. It is agreed that this insurance will not be canceled, not renewed or the limits of coverage in any way reduced without at least (3 0) days advance written notice ten (10) days for non - payment of premium sent by certified mail, return receipt requested to: City of El Segundo City Clerk Attn: Recreation & Parks Director 350 Main Street, Room 5 El Segundo, CA 90245 -3813 CG 20 10 11 85 Copyright, Insurance Services Office, Inc. 1984 Page 1 of 1 OFFER TO RENEW EFFECTIVE NOV 5,13 u/auianesa YOUR COVERAGE EXPIRES ON NOV 5,13. ^- TO KEEP YOUR POLICY IN FORCE, PAYMENT MUST BE RECEIVED /assurance BEFORE NOV 5, 13. IF PAYMENT IS RECEIVED ON OR AFTER -' NOV 5,13, YOUR POLICY BECOMES NULL AND VOID. REMEMBER THERE IS NO GRACE PERIOD AND NO FREE INSURANCE. UNITED STATES HOME OFFICE PLEASE MAKE YOUR PAYMENT NOW. SAN DIEGO, CALIFORNIA POLICY NUMBER POLICY PERIOD INSURED'S PHONE # FA 7297964 NOV 5 , 13 NOV 5 , 14 12:01 A.M. STANDARD TIME AT THE ADDRESS OF =8 18-344-8332 THE NAMED INSURED AS STATED HEREIN NAMED INSURED AND ADDRESS SERVICE OFFICE ADDRESS ERIC GREENBERG WAWANESA GENERAL INSURANCE CO 18560 VANOWEN ST #14 9050 FRIARS RD., SUITE 101 RESEDA CA 91335 SAN DIEGO CA 92108 -5865 TELEPHONE 1- 800 -640 -2920 DESCRIPTION OF OWNED VEHICLES) VEH YR MAKE-DESCRIPTION VEHICLE I.D. NO. COMPUTER IDENTIFICATION 1 09 HONDA,FIT JHMGE88229SO59233 61ON1000044MUPMOOOY11111293213352 2 13 HYUND,ELANTRA KMHDH4AE4DU952103 214N1000048FUPMOOOY11111293213352 INSURANCE IS PROVIDED ONLY WHERE A PREMIUM IS SHOWN FOR THE COVERAGE,. COVERAGE AND LIMITS OF LIABILITY PREMIUMS SEE POLICY FOR COVERAGE DETAILS VEHICLE 1 2 A BODILY INJURY LIABILITY 15,000 EACH PERSON /30,000 EACH OCCURRENCE 221.00 221.00 B PROPERTY DAMAGE LIABILITY 5,000 EACH OCCURRENCE 163.00 163.00 C MEDICAL PAYMENTS 5,000 EACH PERSON 56.00 56.00 D COMPREHENSIVE (EXCL. COLLISION) 500 DEDUCTIBLE 21.00 28.00 E COLLISION 500 DEDUCTIBLE 302.00 397.00 G UNINSURED /UNDERINSURED MOTORIST PROTECTION 30,000 EACH PERSON /60,000 EACH OCCURRENCE 59.00 59.00 I UNINSURED MOTORIST - COLLISION DEDUCT WAIVER 14.00 14.00 TOTALS BY VEHICLE 836.00 938.00 TOTAL POLICY PREMIUM: $1,774.00 PREMIUM DISCOUNTS AVAILABLE: MULTI -CAR; GOOD DRIVER; THEFT RECOVERY SYSTEM; MATURE DRIVER COURSE; DRIVER TRAINING DISCOUNT; PERSISTENCY DISCOUNT PREMIUM DISCOUNTS APPLIED: MULTI -CAR; GOOD DRIVER; PERSISTENCY DISCOUNT APPLICABLE FORMS PAP M # 09/09 ESTMILE11 /12 WAPRVC 05/13 FORM # VEH FORM # VEH FORM # VEH CONTINUED ON NEXT PAGE OF A C C O U N T-- TOTAL PREMIUM $1,774.00 SERVICE CHARGE $12.00 PRIOR BALANCE $25.00 ACCOUNT BALANCE OF $1,811.00 * PAYMENT DUE BEFORE NOV 5,13 EITHER FULL AMOUNT $1,799.00 OR DOWN PAYMENT $738.60 PAYMENTS TO BE BILLED $536.20 DUE FEB 5,14 $536.20 DUE MAY 5,14 '20/10' 9 PAYMENT PLAN ALSO AVAILABLE -1ST PAYMENT IS 20% OF TOTAL PREMIUM PLUS $4.00 SERVICE CHARGE FA 7297964 05 (DEC - 100513 )DB '505 Rev. 1212009 Keep this portion for your records Return this portion with your payment August 25, 2014 To Whom It May Concern, Liberty City contracts our various performers on an "as needed" basis for individual events rather than hiring individuals as employees. All of the performers are independent contractors responsible for their own taxes. Since we have no employees we do not provide workman's compensation. Sincerely, Eric Greenberg 18560 Vanowen St. #14 • Reseda, CA 91335 • office: 818 - 344 -6929 • fax: 818 - 344 -6108 w w w. I i b e r t y c i t y e n t. c o m