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PROOF OF INSURANCE (2013) CLOSEDDAE,MMIDD/YYY) /BIL LIABILITY INSURANCE A C 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(les) 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 endorsemell s:, PRODUCER NiLM E ° Britton- Gallagher and Associates, Inc. PHONE rAX 6240 SOM Center Rd. lyc lILo Exu;44 24 4.71 (Alc, No)„410 44 -1 14cq E•�+kA4L Cleveland OH 44139 A9DRES,$ INSURER(S) AFFORDING COVERAGE NAIC M INSURED INSURERA Lexington 1,risurance, Co, Fireworks & Stage F/X America, Inc. INSURER C: k1Iylr I�Ura� k 018-41 _ g_ DER c: j.. P. O. Box 488 INSLIFkER 0 12650 Highway 67S Ste FA -- { Lakeside CA 92040 INSURER' INSURER F: COVERAGES CERTIFICATE NUMBER: 203576448 REVISION NUMBER: THIS IS T_, C, - RTIF'Y "THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISS9UE'D TO THE INSURED NAMED ABOVE F°OR THE POLUCY 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 .,., ._ _ .. Mai L SUBR TYPE OF INSURANCE POLICY'EFF PO1 D a:XlY.. -... °... .. ° °. ° °° - -..., I R POLICY NUMBER MMa00PYYYY MM70D7YYYY. LIMITS X A GENERAL LIABILITY 1619322 -04 '1111/2012 1/11/2013 EACH OCCURRENCE $1!000,000 �,,, COMMERCIAL GENf Idah1. 4,IAB9G,d PY ........., EIFNISFz -aEa qr R,l,p' aw 350 000 x _ CLAIMS -MADE i OCCUR MED EXP (An one. arson) S PERSONAL &ADVINJURY $1,000,000 GENERAL AGGREGA.... „ „ „............_�.....,- .....,__.._...._.. TE $2,000,000 ._..T :S PER: PRODUCTS COMP /OP AGG µ�$2,000 GEN'L AGGREGATE LIMIT APPLIE. ,000 XPr�.0, .... --- a...._..� .... ..... .. .. .T...- _._...._ 92CyL9l,Y LI1C $ A...•• UTOMOBILE LIABILITY CA626568611 1/1112012 91111201305 L 1 B X ANY AUTO BODILY INJURY (Per person) $ .-..�..... ............._�_,...,� ALL OWNED SCHEDULED BODILY INJURY Per accident S AUTOS AUTOS ( ) X _.- NON OWNED — .- ....... . HIRED X - AUTOS Pera accident DAMAGE 5 ...,.. -. -. -. ( dent) S A x UMBRELLA LIAB X OCCUR .015374896 1/1112012 '1111/2013 EACH OCCURRENCE s4,000,0,00 IRED EXCESS LIAR 5,........ ----- X RETE CLAIMS MADE _NTION 310,000 S WORKERS COMPENSATION WC STATU OTH AND EMPLOYERS' LIABILITY YIN TORy_UMIT`6.,4.. ._ER.. .... —. .......... . ,.. ANY PROPRIETOR /PARTNER /EXECUTIVE OFFICERIMEMBER EXCLUDED? N/A E L EACH ACCIDENT 5 __ (Mandatory In NH) E.L. DISEASE - EA EMPLOYEE $ If yes, describe under �1­11 ...............— _............_ .. - _- ...._.. DESCRIPTION OF OPERATIONS below E,L. DISEASE - POLICY LIMIT 5 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) Show Date: 7/4/2012 Show Time:apprx. 9:00pm Additional Insured: City of El Segundo, El Segundo Fire Department, City of El Segundo Parks and Recreation Department; its officers, agents and employees when acting in their official capacity as such. CERTIFICATE HOLDER CANCELLATION d ( 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 0ep a'rline k1r, 401 Sheldon Street AUTHORIZED REPRESENTATIVE - .,».».,,..,. „ „,....�.. -.. „ „� El Segundo CA 90245 -3813 t AllArm r' ....._.... _� ..... ......�. �w.ua,•�m, - M.......,..mu... ©1988. 010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD POLICY NUMBER _1619322 -04 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;-Off ials, 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 II) 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 ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION REP 04 803053 -12 RENEWAL SD 3- 61 -12 -03 PAGE 1 HOME OFFICE SAN FRANCISCO EFFECTIVE JUNE 5, 2012 AT 12.01 A.M. ALL EFFECTIVE DATES ARE AND EXPIRING JUNE 1, 2013 AT 12.01 A.M. AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME FIREWORKS AMERICA PO BOX 488 LAKESIDE, CA 92040 ANYTHING IN THIS POLICY TO THE CONTRARY NOTWITHSTANDING, IT IS AGREED THAT THE STATE COMPENSATION INSURANCE FUND WAIVES ANY RIGHT OF SUBROGATION AGAINST, EL SEGUNDO, THE CITY OF WHICH MIGHT ARISE BY REASON OF ANY PAYMENT UNDER THIS POLICY IN CONNECTION WITH WORK PERFORMED BY: FIREWORKS AMERICA IT IS FURTHER AGREED THAT THE INSURED SHALL MAINTAIN PAYROLL RECORDS ACCURATELY SEGREGATING THE REMUNERATION OF EMPLOYEES WHILE ENGAGED IN WORK FOR THE ABOVE EMPLOYER. IT IS FURTHER AGREED THAT PREMIUM ON THE EARNINGS OF SUCH EMPLOYEES SHALL BE INCREASED BY 03 %. NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT, COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: 'JUNE 7, 2012 AUTHORIZED REPRESENT A IVE PRESIDENT AND CEO SCIF FORM 10217 (REV.1 -2012) 2570 OLD DP 217 Page 1 of 2 Shilling, Mona From: Garcia, Angelina Sent: Tuesday, June 19, 2012 8:37 AM To: Ramos, Vina Cc: Shilling, Mona Subject: RE: Document: Waiver of Subrogation Looks good. Approved. Angelina Garcia From: Ramos, Vina Sent: Monday, June 18, 2012 5:05 PM To: Garcia, Angelina Cc: Shilling, Mona Subject: FW: Document: Waiver of Subrogation Please advise. Hot item, You have the packet and the waiver of subro was the only one missing. Thanks! Vina From: Ramos, Vina Sent: Wednesday, June 13, 2012 10:15 AM To: Garcia, Angelina Cc: Cummings, Bob; Petit, Meredith Subject: FW: Document: Waiver of Subrogation Angie, Here's another version from Fireworks America. Vina From: Sent: Wednesday, June 13, 2012 10:14 AM To: Ramos, Vina Subject: Fw: Document: Waiver of Subrogation Hi Vina, Finally, it has arrived! Honestly, I don't know why this was so hard, but thank you for your pati( help, please let me know. Jim Amonette 6/19/2012 Page 2 of 2 Fireworks Aiinefta Phone: 619-938-8277 Fax:619-938-8273 iLn_ift_fire%yo�rr iqaS,oLyl - - - - - -- Original Message------ - From: Date: 6/13/2012 10:10:10 AM To Lh11wJLJroK0rn sanjet�igqxonl Cc: In Subject. Document: Waiver of Subrogation Jim, Attached is the Endorsment Agreement for the Waiver of Subrogation. Maribel Hernandez SRU Underwriter The following attachment was sent via State Compensation Insurance Fund's State Fund Online System. If you have received this message in error, please reply to this message and report the error. Your assistance is greatly appreciated. NOTE: Adobe Acrobat Reader (version 7.0 or higher) is required for viewing PDF files. Get it free at: liti %v.gdobccoip/ null This e-mail message from State Compensation Insurance Fund and all attachments transmitted with it may be privileged or confidential and protected from disclosure. If you are not the intended recipient, you are hereby notified that any dissemination, distribution, copying, or taking any action based on it is strictly prohibited and may have legal consequences. If you have received this e-mail in error, please notify the sender by reply e-mail and destroy the original message and all copies. 6/19/2012 P.O. BOX 420807, SAN FRANCISCO,CA 94142 -0807 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 06 -01 -2011 GROUP: POLICY NUMBER: 0803053 -2011 CERTIFICATE EXPIRES: 06-01 -2012 06 -01- 2011/06 -01 -2012 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 cond'i'tions, of such policy. 1 ' `Y11A6a. L Authorized Representative President and CEO EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE EMPLOYER FIREWORKS & STAGE FX AMERICA INC. (A CORP) PO BOX 488 LAKESIDE CA 92040 0410 8rrEV�8.201rb PRINTED : 05-17-2011