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PROOF OF INSURANCE (2015) CLOSEDINLAN -1 OP ID; IL CERTIFICATE OF LIABILITY INSURANCE PtEs',25/14 M /DDNYYY) 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 pollcy((es) 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 Phone: 818-2 C TACr__ TIB Transportation Ir'IS Brokers - Fax:818- 246 -4694 P�kONt 425 West Broadway, Suite 400 Glendale, CA 91204 6MAr. mm " Jack Sandstrom 0, pia ,Ia�:��,1�I :.................._ _., ...�.�...... .......� I W Tt S AFFO 1,glj G INSURERA Lancer Insurance Corn INSURED Inland Empire Stages Ltd. INSURER B 9567 Eighth Street Rancho Cucamonga, CA 91730 -4504 INSURER c INSURER E; 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, LTR TYPE OF INSURANCE I MD IDD r 7CP .EACH OCCURRENCE _ S 2,000,000 .� I� „J�,S, I � POLICY NUMBER kYY'p�� LIMITS GENERAL LIABILITY - _. A rLwMMIf- f4CIAL GENERAL LIABILITY X X ;GL156100 #12 08/31/14 08/31/15 of S 100,000 . CLAIMS MADELL. �...X OCCUR,.. I M EXP 2,000,000 0 PERSONAL S AOV INJURY PENS LAGGREGATE 2,000,00 GLN 'L AGGREGATE LIMIT APPLIES PER PRODUCTS COMP /OP AGO 13 _ a.......... �� ww,.�..� ....... �.. Ltd $ AUTOMOBILE LIABILITY C Ok ISIN :O qh)f l 4 1..9htl 6,000.000 ,C.I�^ !� lu?,Eerr,p w.� �..w _. .- A ANY AUTO X X BA157040 #12 08131114 08/31/15 BODILY INJURY (Per person) S ALL OWNED x 11 LAUTOS ULE O EX AUTOS UTOS URY (Per accident) 5 HIRED AUTOS I X ON -OWNED 6006LY INJURY - - S' __. �tAY�9ta F .u...,...mm ............. I S UMBRELLA A CLAIMUR EACH OCCURRENCE . .. ... EXCESS UAB S MADE AGGREGATE , 5 OCC OEO RETENTIONS WORKERS COMPENSATION nC S fATU AND EMPLOYERS'LIABILITY S S w , �a.. .w l Y P N ANY IaROPRIETOR /PARTNF�R /EXECL)Tl%tE EA._ EACH ACCIDENT S OFF'ICERIMEMBER EXCLUDED? NIA -. (Mandskory In NH) E L DISEASE EA EMPLOYEE S if s, describe under DEsaCRIPYION OF OPERATIONS below, . ._ E L DISEASE POLIC Y LIM ,.$ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more specs Is required) THE CITY Or R'D SEGUNDOyy�, ITS OFFICER'S, OFFICIALS, EMPLOYEES, AGENTS m VOLUNTEERS ADDED AS AIDOXTIONAL INSURED BUT ONLY TO TITS EXTENT" THAT' THE CERTIFICATE &80"GDER IS HELD LIABLE FOR, THE CONDUCT OF THE NAIMED INSURED, "WAIVER OF SUBROGATION APPLIES" "THIS POLICY' IS PRIMARY AMNIA NON-CONTRIBUTORY" �••.. 0000000 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City Of El Segundo ACCORDANCE WITH THE POLICY PROVISIONS. Parks & Recreation C/o City Clerk AUTHORIZED REPRESENTATIVE 350 Main Street Room 5 01988.2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/06) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: GL156100 #13 COMMERCIAL GENERAL LIABILITY CG 20 10 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) ......� .,_ ..... w w..O ,. - _ _. .oc ........� Covered Operations „ r Or �. e Location(s) Of C _�... City of E1, S a g i,.i n. d. a Its Officers, OffJ ...c..J. a :1... r Employees, Agents s and Volunteers 350 Main .Street El Segundo, CA 90245 f" ormation re uj..�. _.....� m ..m g c _. .w___. e....., m .._�,....h ..n � ... _ � eclaratoons r±�d toycom late this Schedule. if not shown above will be shown m 4d"�� [ 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: 1. Your acts or omissions; or 2. The acts or omissions of behalf; in the performance of your the additional insureds) at nated above. on your ongoing operations for the locations g' B. With respect to the insurance afforded to these additional insureds, the following additional exclu- sions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after 1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its Intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. CG 20 10 07 04 0 ISO Properties, Inc., 2004 Page 1 of 1 ❑ CG 20 10 07 04 0 ISO Properties, Inc., 2004 Page 1 of 1 G k) 2 07 (AIP) ENDORSEMENT This endorsement, effect..Lve on 08/3.'1/14 at 12:01 A.M. standard time,for ms a part of Policy No.BA,1,57040#12 of the LANC�.:�.,'R INSURAN(,.,E COMPANY (N&me of insurance company) Iss�.,ied to INLAND E14PIRE STAGES T9['F')- by I.,ANCER INSURANCE COMPANY ;411tKe" Aui)� zed Representative It is hereby understood and agreed that the fc].A.owi ng is added as Additi..onal Insured cn..Ly with re,,..ipects to operation of t-he named J.nsu'r"ed. .................... - Nani.e. C.Lty of El Segundo, Its Officers, Officia.1 s, Employees, Agen.ts and Volunteers 350 in Street El Segundo, CA 90245 ISS�JE 1.)ATE: 08/31/14 Page 1. of '.'I (Ed . 6-7 8) POLICY NUMBER: BA157040#11 COMMERCIAL AUTO CA 04 44 10 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Named Insured: Inland Empire Stages Ltd. Endorsement Effective Date: 10/07/2013 SCHEDULE Name(s) Of Person(s) Or Organization(s): City of El Segundo Parks & Recreation c/o City Clerk 350 Main Street Room 5 El Segundo, CA 90245 Information reouired to complete this Schedule, if not shown above, will be shown in the Declarations. The Transfer Of Rights Of Recovery Against Others To Us condition does not apply to the person(s) or organization(s) shown in the Schedule, but only to the extent that subrogation is waived prior to the "accident' or the "loss" under a contract with that person or organization. CA 04 44 10 13 0 Insurance Services Office, Inc., 2011 Page 1 of 1 INLA1N -1 OP ID: OA ` CERTIFICATE OF LIABILITY INSURANCE DAT0 1221/YYYY) 09122!14 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 endorsemen s . PRODUCER Phone: 818 -246 -2800 4 S West Broadwa I s Br ken N,f?E £' P � - -�� Fax: 818 -246 4690 �c N, ....... E-MAIL _.�. ..._._ Glendale, CA 91204 ARRTM, EWSt AFFORDING COVERAGE NAIC # Republic Indem Co of America SURERe: wsuRED Inland Empire tages IN, _- _ _,. 9567 Eighth Street INSURERC: Rancho Cucamonga, CA 91730 -4504 —"m E5mR_ INSURER D INSURER E : COVERAGES CERTIFICATE NUMBER: REW[SION NUilBER: 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. ... §q .... ._.' � _. ...v._ .,,m........ -_ . �/M. �� �_ -.. POLICY EFF PCk'LfCY EXP ILTR ..... _.._� LIMITS TYPE OF INSURANCE -. w,,,IT POLICY NUMBER _,, , M DIYYYY MM DD„ YYY1(;�� _ _ _ GENERAL LIABILITY EACH OCCURRENCE EREMI& COMMERCIAL GENERAL LIABILITY & b2_gN _ ._.S,_� ?rte.) ... ...... . ,- CLAIMS -MADE � OCCUR MED EXP An one person) $ PERSONAL &ADV INJURY $ GENERALAGGREGATE $ GEN'LAGGREGATELIMITAPPLIESPER! '... PRODUCTS- COMt /OPAGG ��.. -. $ _. ... _...... - -. _.... PR(�» LC3�C PO.. $ -L - _.,_ _ COMWNEO SWGLfiE LIMIT AU7DM0'CY BILE ABILITY Eaanll- _ ...$........ �m.._ ANYAUTO BODILY INJURY (Per person)) $ W ............................... ............................... ALL OWNED �- SCHEDULED BODILYINJURY(Peraccident $. AUTOS _. AUTOS NON -OWNED .�.,� . ".. OP YAMA4aL __.- ..._..�......_.... RED TOS HI AU AUTOS Pvrarrld ent UMBRELLA LU1B CCLAIMS 'EACH 0#,„PwLN6"iR,'9^FCr EXCESS LIAB _ .il -MADE ... y AGGREGATE $ DED RETENTION $ $ _ WORKERS COMPENSATION WC X STATU OTH- YE'MITS AND EMPLOYERS' LIABIIJTY 15669013 /0/01114 10/01/15 A ANY PROPRIEfOR/PARTNERIEXECUTIVE Y!N INlA' X ������� ..W .....00 E L FAC HACCIDENT $ 1 OOO,OO OFFfCERIMEMBER EXCLUDED? (Mandatory in NH) E.L DISEASE EA EMPLOYEE _$ 1,OBBeO� If yes, describe under DESCRIPTION OF OPERATIONS below E L. DISEASE- POLICY LIMIT 1,000,00 DESCRIPTION OF OPERATIONS I LOCATIONS l VEHICLES (Attach ACORD 101 Ad ditlonal Remarks Schedule, if more space is required) - Of£icer Exclusion Applies - Curtis Basey, Nicole Basey CERTIFICATE HOLIER CANCELLATION .-., 0000000 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION PATE THEREOF, NOTICE WILL BE DELIVERED IN City of EI Segundo ACCORDANCE WITH THE POLICY PROVISIONS. Park & Recreational AUTHORIZES REPRESENTATIVE " Attn: City Clerk 350 Main St Room 5 EI Se undo CA 90245 ©1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 {2010105) The ACORD name and logo are registered marks of ACORD WC040306 VYUICILLICJ- LAJIVIrEN1 A.l1U1N Alv1J JtiV1rLUYLKa' L1A151L11 Y rUE1U V Waiver of Our Right to Recover From Others Endorsement - California We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us. You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be otherwise due on such remuneration. Person or Organization CITY OF EL SEGUNDO PARK & RECREATIONAL ATTN: CITY CLERK 350 MAIN ST ROOM 5 EL SEGUNDO, CA 90245 * of the California workers' compensation premium Schedule Job Description ALL OPERATIONS * In lieu of percentage charge to be applied to segregated payroll, we will apply a flat charge of $ 25 per job for those jobs listed above. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. Republic Indemnity Company of America Company No. 19739 Insured: INLAND EMPIRE STAGES LTD Policy Number: 156690 -13 Endorsement Number-. 10 Endorsement Effective: October 01, 2014 Printed on: October 02, 2014 Form No. WC306 10/93 111111 IIIIE IIIII IIIII IIIII Illil IIIII IIIII IIII IIII RFI172P Insured Copy