PROOF OF INSURANCE (2015) CLOSEDMIODUCIR
Momentous Insurance Brokerage
61100 Sepulveda Slvd, Suite 600
Van Nuys, CA 111411
Natalia Ahau•
MMeURED
Alan Margenatern
41213 Sandalwood Circle
Murrleta, CA 92602
Phone: 81 8.933-270C
Fax: B18. 933.2701
THIS IS TO CERTIFY THAT THE POLICIES OIL INSURANCE LISTED BELOW HAVE SEEN ISSUED TO f 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 0E ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT T'O ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN' MAY HAVE BEEN REDUCED BY PAID CLAIMS.
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volunteers are included as Additional =natured as respects �o claims arising
from the negligence of the teamed Xnsureda operations.
SHOULD ANY OF THE ABOVE MCM M POLICIES BE CANCELLED aEFOR!
THE EXPIKATIOI>tiM DATE THEREOF, NOTICE WILL = DELIVERED *1
City of El Segundo ACCORDANCE WITH THE POLICY PROVISIONS.
360 Main Bet Aurnoroaao REPRSISNTATwa
El Segundo, CA 9024
Natalie Ahaue
®198-8,2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010108) The ACORD name and logo are registered math of ACORD
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The City of 41 sagur4o, its officers officials, aMvloyaee agents, and
volunteers are included as Additional =natured as respects �o claims arising
from the negligence of the teamed Xnsureda operations.
SHOULD ANY OF THE ABOVE MCM M POLICIES BE CANCELLED aEFOR!
THE EXPIKATIOI>tiM DATE THEREOF, NOTICE WILL = DELIVERED *1
City of El Segundo ACCORDANCE WITH THE POLICY PROVISIONS.
360 Main Bet Aurnoroaao REPRSISNTATwa
El Segundo, CA 9024
Natalie Ahaue
®198-8,2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010108) The ACORD name and logo are registered math of ACORD
Form W
(Rev. August 2013)
Department of the Treasury
Internal Revenue Service
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(as shown on your income tax
Request for Taxpayer
Identification Number and Certification
Productions, LLC
lysretfarded entity name, if ci fle ant from
Give Form to the
requester. Do not
send to the IRS.
Check appropriate box for federal tax classification: Exemptions (see instructions):
❑ Individual /sole proprietor ❑ C Corporation ❑ S Corporation ❑ Partnership ❑ Trust/estate
Exempt payee code (if any)
❑✓ Limited liability company. Enter the tax classification (C =C corporation, S =S corporation, P= partnership) ► S I Exemption from FATCA reporting
code (f any)
Other (see instructions) ►
ass (Mrrrbor, street, and apt, or suite no.)
41213 Sandalwood Cir
City, state, and ZIP code
Murrieta, CA 92562
List ac dount number(s) here {o
name
EM Taxpayer identification Number Ttl
Enter your r TIN I the Individuals, sIN proividetdmr serial match the name given on the ' "iNarna " line Social security number
to Y pp p
number (SSN). However, for a
resident alien, sole proprietor, or disragarded entity, sea the Fart I instructions out page 3. For other
entities„ it is your employer identification number (EIN), If you do not have a number, see How to get a
TIN on pane 3.
Note. If the account is In more than one name, see the chart on page 4 for guidelines on whose Employer iderffflcation number
number to enter.
3 3 — 0 1 9 1 6 1 41 0 1 0 1 5
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
2. 1 am not subject to backups withholding because: (a) I am exernpt from backup withholding, or (b) I have not been notified by the Internal Revenue
Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am
no longer subject to backup withholding, and
3. 1 am a U.S. citizen or other U.S. person (defined below), and
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding
because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage
interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and
generally, payments other than interest and dividends, you are not required to sign the cortiffoation, but you must provide your correct TIN. See the
instructions on page 3.
Sign Signature of
Here I U.S. person ► Date ► 03/30/2014
General Instructions
Section references are to the Internal Revenue Code unless otherwise noted.
Future developments. The IRS bias created a page mw IRS.gov for Information
about Form W-9, at ww %vJrs.govA v9. Information about any future developments
affecting I -airn W-9 (such as legislation enacted after wo release it) will be posted
on that page.
Purpose of Form
A pvfson who is roqumlrtad to tile an information return with the IRS must obtain your
cmrom taxpayer klonlification, number (TIN) to report, tot example, Incorne paid to
you, payments rrmado to you In sattloment of payment card and third party network
tratrsacttorms, root estate transactiion$, awrtgage Interest you paid, acquisition or
abandonment of secured property, cancellation of debt, or contributions you made
to an IRA.
Use (worm W -9 only if you am a. U.S. person (including a resident alien), to
provide your comroct TIN to the person requesting it (the requester) and, when
applicable, to:
1. Certify that the TIN you are giving is correct (or you are waiting for a number
to be Issued),
2. Certify that you are not subject to backup withholding, or
3, Claim exernptlon frorn backup withholding It you are a U.S. exempt payee. If
of
withholding tax on foreign partners' share of effectively connected income, and
4. Certify that FATCA code(s) entered on this form (if any) Indicating that you are
exempt from the FATCA reporting, Is correct.
Note. If you are a U.S. person and a requester gives you a form other than Form
W -9 to request your TIN„ you n'MUSt use the requester's form If it is substantially
similar to this Form W -9.
Definition of a U.S. person. For federal tax purposes, you are considered a U.S.
person if you are:
• An Individual who is a U.S, citizen or U.S, resident alien,
• A partnership, corporation, company, or association created or organized in the
United States or under the laws of the United States,.
• An estate (other than a foreign estate), or
• A domestic trust (as defined in Regulations section 301.7701 -7).
Special rules for partnerships. Partnerships that conduct a trade or business In
the United States are generally required to pay a withholding tax under section
1440 on any foreign partners" share of effectively connected taxable income from
such business, Further, in certain cases where a Form W -9 has not been received,
the rules under section 1440 require a partnership to presume that a partner is a
foreign person, . and pay the section 1446 withholding tax, Therefore, If you are a
U.S, person that is a partner in a partnership conducting a trade or business In the
United Status, provide Form W -9 to the partnership to establish your U,S. status
and avoid section 1440' withholding on your share of partnership income,
applicable, you are also certifying that as a U.S. person, Your alior.abie share
any partnership income from a US, trade or busyness Is not subject to the
Cat. No. 10231X Form W -9 (Rev. 8 -2013)
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.
C. With respect to the insurance afforded to these
additional insureds, the following is added to
Section III - Limits Of Insurance:
CO2010 413
Insurance ServIcesOfBce, Inc„ 2012
I
If coverage provided to the additional insured is
required by a contract or agreement, the most we
will pay on behalf of the additional insured is the
amount of insurance:
1. Required by the contract or agreement; or
2. Available under the applicable Limits of
Insurance shown in the Declarations;
whichever is less,
This endomerne;nt shall not increase the applicable
Limits of Insurance shown in the Declarations.
Page 2 of 2
4641
Additional Insured - Owners, Lessees or Contractors - Scheduled
Person or Organization - CG 20 10 04 13
Policy Amendment(s) Commercial General Liability
Insured: MORNINGSTAR PRODUCTIONS LLC
Producer: MOMENTOUS INS BROKERAGE, INC
Policy Number: E 92 XPK 80955518
Effective Date: 04-10-14
This endorsement modifies insurance provided under the following:
Commercial General Liability Coverage Part
Schedule
Name Of Additional Insured Person(s) Or Organization(s) Location(s) Of Covered Operations
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
A. Section H - Who Is An Insured is amended to 2. If coverage provided to the additional insured
include as an additional insured the person(s) or is required by a contract or agreement, the
organization(s) shown in the Schedule, but only insurance afforded to such additional insured
with respect to liability for bodily injury, property will not be broader than that which you are
damage or personal and advertising injury caused, required by the contract or agreement to
in whole or in part, by: provide for such additional insured.
1. Your acts or omissions; or
2. The acts or omissions of those acting on your
behalf;
in the performance of your ongoing operations for
the additional insured(s) at the location(s)
designated above.
However:
The insurance afforded to such additional
insured only applies to the extent permitted
by law; and
B. With respect to the insurance afforded to these
additional insureds, the following additional
exclusions apply:
This insurance does not apply to bodily injury or
property damage occurring after:
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
This Form must be attached to Change Endorsement when issued after the policy is written.
One of the Fireman's Fund Insurance Companies as named in the policy
Secretary President
CG2010 4 -13
® Insurance 5ervicesOffice, Inc„ 2012
Page I of 2
64 1
6a
Workers' Compensation and Employers' Liability Insurance Policy
Waiver of Our tight to Recover From Others Endorsement - California
WC 04 03 06
If the following information is not complete, refer to the appropriate Schedule attached to the policy.
Insured: Morningstar Productions, LLC
Producer: Momentous Insurance Brokerage
Schedule
Person or Organization:
Ciy of El Segundo
Its officials, employees, agents and volunteers
350 Main Street
El Segundo, CA 90245
Additional Premium %
We have the right to recover our payments from any-
one 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.)
Policy Number: XWC81019345
Effective Date: 04/10/2014
You must maintain payroll records accurately segre-
gating the remuneration of your employees while en-
gaged in the work described in the Schedule.
The additional premium for this endorsement shall be
the percentage, as shown in the Schedule applicable to
this endorsement, of the California workers' compen-
sation premium otherwise due on such remuneration,
This Form must be attached to Change Endorsement when issued after the policy is written,
One of the Fireman's Fund Insurance Companies as named in the policy
WC0403064 -84
�OM �
President