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PROOF OF INSURANCE (2013) CLOSEDA�` DATE (MWDD/PYYY) CERTIFICATE OF LIABILITY INSURANCE 05106/2013 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 i CONTACT Jerry Glenn : NAME, Western Sentry Insurance Brokers AIC No 805- 577 -8522 F Nc,. 888 875 -2902 4212 E Los Angeles Ave #9 I ADDRESS westemsentry@gmail.com Slml Valley CA 93063 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA: Atlantic Specialty Insurance Co / One Beacon Michael Bell INSURER B: dba: Bell Event Services INSURER C: 3206 Galli St INSURER D: Hawthorne CA 90250 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. fLSR TYPE OF INSURANCE PNSR WWVD POLICY NUMBER MWOONYY Y) IMMIDDIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 COMMERCIAL GENERAL LIABILITY RENTED $ 100,000 CLAIMS -MADE © OCCUR , PREMISES EX WS (Any on�rapers n ED EXP (Any one person) $ 1,000 PERSONAL & ADV INJURY $ 1,000,000 A x GL00248 -03 10/25/12 10/25/13 T GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG '.$ 2,000,000 GE.N'L AGGREGATE LIMIT APPLIES PER: - -„ PROD- ...... POLICY . p LOC ,.. AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT .........., (Ea accident) $ ANYAUTO BODILY INJURY (Par person) $ ALLOWNEDAUTOS BODILY IN JURY Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS (Per accident) $ $ NON -OWNED AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXC EBB LIAB CLAIMS -MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND 7O"LRY LIMITS ER T- EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE —q E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? H N/A (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more apace Is required) Additional Insured: City of El Segundo, its officers, officials, employees, agents and volunteers As per CG 20 26 07 04 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE City of El Segundo EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH 360 Mein St Rm 5 THE POLICY PROVISIONS. El Segundo CA 90245 -3813 AUTHORIZED REPRESENTATIVE Certified Signature -- --- ----- -- --------- --y - -- -Jerry Glenn 01988 -2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. POLICY CHANGES Policy Change 1 Number POLICY NUMBER POLICY CHANGES COMPANY GL00248 -04 EFFECTIVE Atlantic Specialty Insurance Company 05 -22 -2013 NAMED INSURED AUTHORIZED REPRESENTATIVE Michael Bell & Vanessa Bell COVERAGE PARTS AFFECTED General Liability Coverage Part CHANGES As respects; City of El Segundo The following form is added and attached: Additional Insured - Designated Person or Organization - CG 20 26 07 04 Annual TRIA: $5 Factor: 1 Total Premium for this Endorsement: $255 State Fee Changes: $0 Total Due for this Endorsement: 255 IL 12 01 11 85 Copyright, Insurance Services Office, Inc., 1983 Page 1 Copyright, ISO Commercial Risk Services, Inc., 1983 IL 12 01 11 85 Copyright, Insurance Services Office, Inc., 1983 Page 2 Copyright, ISO Commercial Risk Services, Inc., 1983 POLICY NUMBER: GL 00248 -03 COMMERCIAL GENERAL LIABILITY CG 20 26 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance prouded under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE 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 ad%ertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf.• A. In the performance of your ongoing operations; or B. In connection with your premises owned by or rented to you. CG 20 26 07 04 D ISO Properties, Inc., 2004 Page 1 of 1 ❑ THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. POLICY CHANGES Policy Change 2 Number POLICY NUMBER POLICY CHANGES COMPANY GL00248 -04 EFFECTIVE Atlantic Specialty Insurance Company 05 -22 -2013 NAMED INSURED AUTHORIZED REPRESENTATIVE Michael Bell & Vanessa Bell COVERAGE PARTS AFFECTED General Liability Coverage Part CHANGES The following form is added and attached: Additional Insured - Owners, Lessees or Contractors - Completed Operations - CG 20 37 Factor: 0.427 Total Premium for this Endorsement: $0 State Fee Changes: $0 Total Due for this Endorsement: 0 IL 12 01 1185 Copyright, Insurance Services Office, Inc., 1983 Copyright, ISO Commercial Risk Services, Inc., 1983 Page 1 POLICY NUMBER: COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Or anization s : Location And Description Of Completed O erations City of El Segundo, its officers, officials, emp oy es„ TBD agents and volunteers 360 Main Street, Room 5 El Segundo, CA 90245 -3813 Information required to complete this Schedule if 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" or "property damage" caused, in whole or in part, by "your work" at the location designated and described in the schedule of this endorsement performed for that additional insured and included in the "products -completed operations hazard ". CG 20 37 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 ❑ Progressive P.O. Box 94739 Cleveland, OH 44101 1- 800 - 895 -2886 Certificate of Insurance Certificate Holder MICHAEL! BELL 531 MAIN ST #229 EL SEGUNDO, CA 90245 Insured . ............................... MICHAEL BELL VANESSA E BELL BELL EVENT SERVICES 531 MAIN ST #229 EL SEGUNDO, CA 90245 Policy number: 04315274 -3 Underwritten by: Progressive Express Ins Company May 17, 2013 Page 1 of 1 Agent .............. I............................. PROG COMMERCIAL PO BOX 94739 CLEVELAND, OH 44101 This document certifies that insurance policies identified below have been issued by'the designated insurer to the insured named above for the period(s) indicated. This Certificate is issued for information purposes only. It confers no rights upon the certificate holder and does not change, alter, modify, or extend the coverages afforded by the policies listed below. The coverages afforded by the policies listed below are subject to all the terms, exclusions, limitations, endorsements, and conditions of these policies, Policy Effective Date: Aug 21, 2012 Insurance coverage(s) ............... ............................... Bodily Injury/Property Damage Description of Location/Vehicles /Special Items Scheduled autos only Certificate number 13713AO8274 .,o .. .... ... .................... ....... '..... .............. .., ......._. ,.. .... Policy Expiration Date: Aug 21, 2013 Limits ........I ... ................ ... ..................,,,.. „ „,,.,.. ,..,,,... ..,,..,,......o...,....., $750,000 Combined Single Limit Please be advised that the certificate holder will not be notified in the event of a mid -term cancellation. "(2-11-t- Form 5241 (10/02) Biel SUBJECT. City of El Segundo Sole Proprietor /Partnership /Closely Held Corporation with No Employees Please let this memorandum notify the City of El Segundo that I am a Closely held corporation and do not have any employees whose employment requires me to carry workers' compensation insurance. Therefore, I do not carry worker's compensation insurance coverage.