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PROOF OF INSURANCE (2013) CLOSEDI* CERTIFICATE OF LIABILITY INSURANCE DATE(MM /2012 Y) 09/27/2012 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 C Nra T Stephanie Weiss RJF Minneapolis 7225 Northland Dr N #300 Minneapolis, MN 55428 INSURED Performers of the U.S. & Club Members Phone: 715- 246 -8908 Fax: 715 - 246 -4257 Attn: Stephanie Weiss PO Box 24 New Richmond, WI 54017 INSURER B: INSURER C: INSURER D: INSURER E: ). 715- 246 -8908 certs @specialtyinsuranceagency.com ORDING COVERAGE Lexington Insurance Company COVERAGES CERTIFICATE NUMBER: RFVISInN NIInnRI =R• 715 - 246 -4257 NAIC # 19437 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. PdiSRAC)dU't w TYPE OF INSURANCE POLICYEFF POLICY' ExP LIMITS tLTft POLICY NUMBER MMFDDIYYYY MMPDD6YYYY' GENERAL LIABILITY EACH OCCURRENCE $ 3,000,00 X COMMERCIAL GENERAL LIABILITY PREMIS i,( r�1 ccurr� mm , 100,000 CLAIMS-MADE .,X )OCCUR MED EXE y person) '.. . $ 5,000 A X LX9776 08/04 X X 014245884 04/25/12 04125/13 PERSONAL $ nov INJURY $ 3,000,000 X LX0404 GENERAL AGGREGATE $ 5,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 5,000,000 PRO X POLICY LOC _. $ AUTOMOBILE LIABILITY fYVN ED SING1E LIMIT (F acsir,I,ent1__. ,.m . $ ........... ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS .,.......,,U BODILY URY Y IN (Per accident) $ NON-OWNED NED HIRED AUTOS ( cRtY AMAUP PeOac $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ y EXCESS LIAB CLAIMS MADE AGGREGATE GATE $ DED RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS' LIABILITY Y / N , - „ „TO,RY LIMIT..] Ems.... ANY PROPRIETOR/PARTNER/EXECUTIVE EL EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? NIA (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ If yes, describe under .,. DESCRIPTION OF OPERATIONS below E . DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS I 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 insorfar as the operations under this contract are concerned. Fax: 310 - 640 -7720 Attn: Pamella Roach ............ 0 y CERTIFICATE CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of El Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main Street, Room 5 ACCORDANCE WITH THE POLICY PROVISIONS. El Segundo, CA 90245 -3813 AUTHORIZED REPRESENTATIVE @ 1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 014245884 COMMERCIAL GENERAL LIABILITY CG20 26 07 04 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 Additional Insured Person(s) or Organization(s) Premises Location: City of El Segundo City Clerk Attn: Recreation & Parks Director 350 Main Street, Room 5 El Segundo, CA 90245 -3813 Additional Insured: The City of El Segundo, its officers, officials, employees, agents & certified volunteers 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. Information required to complete this Schedule, if not shown above will be shown in the Declarations. 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 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 ©ISO Properties, Inc., 2004 Page 1 of 1 ENDORSEMENT # 011 This endorsement, effective 12:01 AM 04/25/2012 Forms a part of policy no.: 014245884 Issued to: PERFORMERS OF THE U.S. CLOWNS OF THE U.S. By:LEXINGTON INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED REQUIRED BY WRITTEN CONTRACT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY POLICY, COVERAGE APPLICABLE TO COVERAGE A. BODILY INJURY AND PROPERTY DAMAGE (SECTION I - COVERAGES) ONLY A. Section II - Who Is An Insured is amended to include any person or organization you are required to include as an additional insured on this policy by a written contract or written agreement in effect during this policy period and executed prior to the "occurrence" of the "bodily injury" or "property damage." B. The insurance provided to the above described A additional insured under this endorsement is limited as follows: 1. COVERAGE A BODILY INJURY AND PROP- ERTY DAMAGE (Section I - Coverages) only. 2. The person or organization is only an additional insured oath respect to liability arising out of "your work" or "your product ". 3. In the event that the Limits of Insurance provided by this policy exceed the Limits of Insurance required by the written contract or written agreement, the insurance provided by this endorsement shall be limited to the Limits of Insurance required by the written contract or written agreement This endorsement shall not increase the Limits of Insurance shown in the Declarations pertaining to the coverage provided herein. 4 The insurance provided to such an additional insured does not apply to "bodily injury" or "property damage" arising out of an archi- tect's, engineer's, or surveyor's rendering of or failure to render any professional services, including, but not limited to: I. The preparing, approving, or failing to prepare or approve maps, shop dravangs, opinions, reports, surveys, field orders, change orders, or dravangs and specifications; and ii. Supervisory, inspection, architectural, or engineering activities. 5. This insurance does not apply to "bodily injury" or "property damage" arising out of "your work" or "your product" included in the "product-completed operations hazard" unless you are required to provide such coverage by written contract or written agreement and then only for the period of time required by the written contract or written agreement and in no event beyond the expiration date of the policy. 6. Any coverage provided by this endorse- ment to an additional insured shall be excess over any other valid and collectible insurance available to the additional insured whether primary, excess, contingent or on any other basis. C. In accordance with the terms and conditions of the policy and as more fully explained in the policy, as soon as practicable, each additional insured must give us prompt notice of any "occurrence" which may result in a claim, forward all legal papers to us, cooperate in the defense of any actions, and otherwise comply with all of the policy's terms and conditions. Failure to comply with this provision may, at our option, result in the claim or "suit" being denied. e Authorized Representative OR Countersignature (In states where applicable) Includes copyrighted information of the Insurance Services Offices, Inc., with its permission. All rights reserved. LX9776 (08104) r SDA 2950 NON - ASSESSABLE POLICY PAGE 2 FAMILY COMBINATION AUTO POLICY r. !(/aF, Vw HMO NEW DECLARATION * * * * * EFFECTIVE NOV 5,111 h7WM,7ce _QE:N _-AL__O `mot - OMPANY'. UNITED STATES HOME OFFICE SAN DIEGO, CALIFORNIA POLICY NUMBER !21JCY PERIOD fNSUREO'S PHONE 8 FA 7297964 NOV 5,11 NOV 5,12 ERIC GREENBERG 18560 VANOWEN ST N14 RESEDA CA 91335 f 2:Ot A.M. STANOARO TIME AT THE ADORESS OF THE NAMED INSURED AS STATED HEREIN SERVICE OFFICE 818- 344 -8332 WAWANESA GENERAL INSURANCE CO 9050 FRIARS RD., SUITE 101 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 96 TOYOT,COROLLA DX INXBB02ESTZ469051 D10N1000046FUPM101Y11111293213352 2 09 HONDA,FIT JHMGESS22SS059233 41ON1000042MUPMODOY11111293213352 INSURANCE IS PROVIDED ONLY WHERE A PREMIUM IS SHOWN FOR THE COVERAGE. COVERAGE AND LIMITS OF LIABILITY PREMIUMS VEHICLE 1 2 A BODILY INJURY LIABILITY 15,000 EACH PERSON /30,000 EACH OCCURRENCE 259.00 174.00 B PROPERTY DAMAGE LIABILITY 5,000 EACH OCCURRENCE 276.00 186.00 C MEDICAL PAYMENTS 5,000 EACH PERSON 69.00 46.00 D COMPREHENSIVE (EXCL. COLLISION) 500 DEDUCTIBLE 44,00 39.00 E COLLISION G 500 INSUR 364.00 320.00 D /UNDERINSURED MOTORIST PROTECTION 30,000 EACH PERSON /60,000 EACH OCCURRENCE 64.00 43.00 I UNINSURED MOTORIST - COLLISION DEDUCT WAIVER 14.00 14.00 TOTALS BY VEHICLE 1090.00 TOTAL POLICY PREMIUM: $1,912.00 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 APPLICABLE FORMS FORM N VEH FORM M VEH FORM M VEH FORM M VEH FORM PAP 09/09 NBLETR * ALL WAPRVC 08/03 DRIVER NAME(S)r GREENBERT�„ KLOTZ,� A - -S T A T E M E N T O F A C C­0 U N T -- TOTAL PREMIUM E . 00 AMOUNT RECEIVED ACCOUNT - BALANCE OF 5331,00 $1,581.00 $331.00 DUE UPON RECEIPT FA 7297964 03 (DEC - 110211 )DB W-QM R -, 1220= Keep this Portion for your records 622.00 VEH FORM N VEH _ fiber + ._ CITY September 24, 2012 To Whom It May Concern, Liberty City contracts our various performers on an "as needed" basis for individual events rather than hiring individuals a loyees. All of the performers are independent contractors responsible for it o taxes. Since we have no employees we do not provide workman's comcensato �, / Sincerely, Eric Greenberg 18560 Vanowen St. #14 - Reseda, CA 91335 - office: 818 - 344 -6929 - fax: 818 -344 -6108 www.Iibartycityent. c o m