PROOF OF INSURANCE (2012) CLOSED05/10/2011 08:58 6199388273
PAGE 02/02
DATE (MM1DorrYrn
CERTIFICATE OF LIABILITY INSURANCE I 3/2S/2011
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
BELOW. HIS CERTIFICATE F OF INSURANCE OESANIOTLCONST TUNE EXTEND OR ALTER THE A CONTRACT BETWEEN COVERAGE
THE ISSUING NSURER(S)TAUTHOR AUTHORIZED
REPRESENTATIVE OR D THE CERTIFICATE HOLDER.
IMPORTANT. IF tho ertRODo holder is an ADDITIONAL INSURED, the pollCY003) must tyB e'ndOrsad. it SUIBROCAi IOhI tS WAz4V'ED, subjoC( to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this eantIficate does not confer rights to the
certificate holder In lieu of such endor:sembnt(s),.
PRODUCER NAMI'S.^
Britr:on- Gallagher and Associatts, Inc, Pi N c 44,„12Z4
6240 SOM Center Rd. L@IA7L
Cleveland OH 44139
A @tLIII
.. �,.,........,..wr,anwrrum- r•nwreweca NAIL N
INSURED
Fireworks & Stage FIX America, Inc,
P. 0, Box 489
12650 Righway 67S Ste FA
L,la,keeide CA 92040
COVERAGES CERTIFICATE NUMBER: 35
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LMTEO SELC
PERIOD INDICATED NOTMI THSTANDWO ANY REQUIREMENT, TERM C
WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE tNS
TO ALL THE TERMS EXCLUSIONS AND CONDITIONS OF SUCH POLICII
014
.TYPE OF INSURANOt` POL'IC,
A OENERALLIABILITY 1614132 -03
X OOA4MEACIALGENFJ;Ar .LIABILITY
CLAIMS -MADE ED OCCUR
EG N'L AGOIREOATE LIMIT APPLIES PER:
B AUTOMOBILE LIABILITY
X ANYAUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
X NON•OINNED AUTOS
C UMBRELLA LIAR
x EXCESS LIAO
DEDUCTIBLE
AND EMPLOYERS' LIABILITY
OCCUR
Y1N
7 I N)A
56961D
PAU720120
A:
Cs
16416 REVISION NUMBER'
ED ABOVE FOR THE POLICY
DOCUP4ECJT WITH RESPPOT TO
HERENN l5 SUBIECT
BY PAID CLAIMS,
LIMITS
EACH OCCURRENCE 11,000,000
P�tB " ■ o cwrrAM��O� ,x,50, 900
LIED V(P (My ora araar. S
PEFNSONALSAD'arINJ�JRY
........
X1,000,900
GENERAL A GRE0AI"
N ?,000,000
PRSOO'MJCT9 - 0'O).PlOPAGG
41.000,090
Z
COMBINED SINGLE LIMIT
S] " 000, 000
(Ee acdd■nly
BODILY INJURY IPar per in)
6
BODILY INJURY (Par scxJdanl)
S
PROPERTY DAMAGE
9
(Per accldant)
EACH OCCURRENCE',
Sti,009,090
AGGREOVATE -
SA .000, 000
8
S
O "
E L. EACH ACOOLNT
E „L DISEASE « FA EMPLOYEE
S
G. L. OISEASIE . POLICY LIMIT S
)n, Park
El Segundo Parke and
mir official capaci ae :such,
HAVE BEEN MSUFO TO THE INSURED NAM
CONDITION OF ANY CONTRACT` OR OTHER
ANCE AFFORDED DY THE POLICIES DESCRIBED
LIMITS SHOWN MAY HAVE BEEN REDUCED
011 111/1111012
2011 11/11/2012
1/1112011 11/11/20,1?
DESCRIPTION OF OPERATIONS r LOCATIONS 1 VEHICLP_S (Attach ACORD 101. Additional Remarks S"edula, It more ■pace Is raQUNred)
show Date: 7/4/2011 Show Time:apprx. 9:00pm show Location: Recreatl�
Additional Insured: City of E1 Segundo, E1 Segundo Fire Department, City o
Recreation Dra artment, its officers aqents and em 10 ees ashen. ,actin in t
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF NOTICE WILL BE DELIVERED
IN ACCORDANCE WITH THE POLICY PR4V6I0NS.
City of E1 Segundo
Parke & Recreation Department
401 sheldan Street AUTHORIZED REPRESENTATIVE
£1 Segundo CA 90245 -3813
01988 -2009 ACORD CORPORATION. All rights reserved.
ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD
POLICY NUMBER: 1619322 -03
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, Officials, Employees, Agents, & Voluntee
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
PU iCYHOII DER COPY
;H
F',0- BOX 420807, SAN F"RAN IIS „ A ,414 —0 i7
This is to certify thW we 8'reawm issued a w,slikd ''ans°a~ Irkeirs° Coriapte n saatdom insurance paoficy in a fforrvu approved by tpaar
CaiHorn iia insurance Copnirissprirser to the eirnpioVer a arnirvd i)citow for the y^arr ,)9iCy period indicated,
Pfls Poiicy is not subject to aaLanceltlanffmirn by the I1 ::: und except upon 30 dates advance written n" olo ce to the eranp ioyaer.
We will aVso give you 30 days advance notice sitouid this Ipeapdcy be earn eiied prior to its nor-mall aexp;ra 6aam.
"9hd s certihicate of 6suraurwcoa is rro t are insuaaut m pa(Acy and does) not arnend, oxtend or a4ar Ore coverage afforded
by the g Ii y het d dwer Ot V`' otwtrnth5tau�niding arny reapsrnreimrearut.,termi� r, condition of any contract or other, document
wrw ah respect to which this certificate p rns unrar)ce wroy be r'ssnaewnd or tab wwiai h it may perta n,, the insurance
afforded by the policy y described horaairr is subject to a0 Vie t rn ,is, ex0uw6ns, and condrtie ns, of such policy
',
; ohor °ized Igeppresa„rnt tdwrce interun Prasi.dent and Cl!i €O
t'MMIgLICDy`ER' ff,.TAd131(II,,,,ITY t,,,,'IMIT INC11,,,A,AIDIN IDEFIWNSE t,OSTS� S1,000,000 PER OCCURRIENCE,
EMPLOYER
FIREWORKS & STAGIII: FX AMERICA INC,, (A CORP)
P'0 BOX 488
LAdiCESUDIE Cat 92040
flPIO,SD]
tmr'V, n .2 0 ,a ren PRINTED � 05-25-2010