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PROOF OF INSURANCE (2015) CLOSEDCERTIFICATE OF LIABILITY INSURANCE 314/15ID°nYYY' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOTAFFIRMATIVELY OR NEGATIVELY AM END, 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 carliBcate holder Is an ADDITIONAL INSURED, the policy(les) must be endorsed. It 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 endorsemwMs). PRODUCER Ruth Carter Thompson Insurance Enterprises LLC ruc W. F.H. 676 - 2911 -213n IWAIL 3380 Chastain Meadows Pkwy, Ste. 100 Ardvm". RUth.Carterothomcoins -com watmih Kennesaw, GA 30144 INS S AFFORDNNGCOVERAGE NwCde IN NtED INSURFRA : Essex Insurance Crlmnanv 39020 Elite Special Events Inc INSumRs : National Union Fire Ins Co of Pittsburgh PA 19"S 11278 Los Alamitos Blvd INSURERC : #101 INSURER D : Los Alamitos, CA 90720 INSURER E : INSURERF COVERAGES CERTIFICATE NUMBER: 681027 REVISION NUMBER: ioi 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 CONTRACTOR OTHER DOCUMENT WITH RESPECTTO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BYTHE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONSAND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS. PO TYPE OF MLMNCE 111w= WVD POLICY NUMBER ONMAMM' UMRS GENERAL LUUMM EACH OCCURRENCE $1,000,000 COMMERCIAL GENERAL LIABILITY PREallms 9A t�R S 100.000 CLAIMS -MADE x❑ OCCUR X FPG20005135 -02 10/28/14 10/28/15 MED EXP (Any one person) s Excluded A PE&RSON+RAL s ADY N..URY' $1,000.000 GENERAL AGGREGATE s 2_n_nn_nnn G NIL AGGREGATE L HIT APPLIES PIER: PRODUCTS - COMPIOPAGG 52.000.000 Poucy PR LOC $ AUTOMOBLE Lu=LnY COMBINED SINGLE LIMB $ (Ea socideM) ANY AUTO ALL OWNED SCHEDULED BODILY INJURY (Per person) _ AUTOS AUTOS BODILY INJURY (Pereoddart) j $ HIREDAUTOS NON -OWNED AUTOS PROPERTYDAMAGE S (Per ecddent) S UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESSLIAS CLANS-MADE AGGREGATE $ DIED L_jkTENT i WORKERS COMPENSATION A AND EMPLOYERS'LIABLnY YIN ANY FROFRIETORIPARTTEt1EXECUTIVE❑ NIA E.L. EACH ACCIDENT S OFFICERIMEMBER EXCUlDED7 (Mandatory 1" NH) E.L. DISEASE - EA EMPLO " $ tU"MI+'R'kONOF OPERATIONS below E.L. DISEASE - POLICY LIMIT S -T B Accident & Health SRG9111254 -A -4175-0 0 10/28/14 10/28/15 P!en c $ 15,000 s DESCRIPTION OF OPERATIONS! LOCATIONS 1vEHICLES (ANachACORD 701, AdMonel Rsma*x $she", Inman space Is rertnlredt Certificate Holder is an Additional Insured per the attached CG 20 26 07/04 endorsement ACORD 25 (2010=) The ACORD name and logo are registered mark* of ACORD THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. POLICY NUMBER FPG20005135 -02 POLICY CHANGES POLICY CHANGES EFFECTIVE 3/4/15 NAMED INSURED Elite Special Events Inc 11278 Los Alamitos Blvd #101 Los Alamitos, CA 90720 COVERAGE PARTS AFFECTED Commercial General Liability Coverage Part CHANGES The following additional insured is ADDED: Additional Insured Name and Address: City of el Segundo 350 Main Street El Segundo, CA 90245 It Is agreed that the following form is added: Form # Description CG 20 26 07 04 Additional Insured - Designated Person or Organization All other terms and conditions remain unchanged. Policy Change Number 11 COMPANY Essex Insurance Company AUTHORIZED REPRESENTATIVE Greg Thompson Authorized Representative Signature IL 12 011185 Copyright, Insurance Services Office, Inc., 1983 Page 1 of 1 POLICY NUMBER: FPG20005135-02 COMMERCIAL GENERAL LIABILITY CG 20 26 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. • nr 1� A This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART M el Segundo ain Street El Segundo, CA 90245 SCHEDULE not shown above, will be Section II - Who Is An Insured is amended to in- clude 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 omis- sions 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. in the Declarations. CG 20 26 07 04 ® ISO Properties, Inc., 2004 Page 1 of 1 ' ��YA CERTIFICATE OF LIABILITY INSURANCE I 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 cartlficate holder Is an ADD17IONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, sUb(ec -t 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 andorsomen!LGI. PRODUCER Leslie Donovan Nielsen MrAnany Insurance Services, Inc. ANON, F..,. (805)379 -8801 (805)204-,9302 4165 E. Thousand Oaks Blvd Suite 325 IN§URVAM A 'OROING COVP�tK NAIC 8 Westlake Village CA 91362 INSURERA:Golden Eacrle INSURED 0- 01IRea R Elite Special Events, Inc. INSURER C: 404 N. Sparks Street INSURER Burbank CA 91506 RISURBR E ' COVERAGES CERTIFICATE NUMBER;CL149801215 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. NOTVATHSTANDING 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 ME OF INSURANCE seurw uuuIRER _, ,.._,.� -ti. Dn m MrraoawYYYY LIMITS GENERAL LIASLITY EACH OCCURRENCE S COMMERCE GENERAL UAOLITY RENTED oow171Ce. I S CLAJMS -MADE 1:1 OCCUR MED EXP 1Arn afs oenonl SMM PERSONAL A, ASV INJURY S GENERAL AGGREGATE $ PRODUCTS'•COMPIOPAGG S GEN'LAGGREGATE. LIMIT APPLI PER; POLICY M PT; "s I S AUTOMOBILE LIABILITY EIRIT s 1.00D_nng BODILY INJURY (Per paean) _., S A ANY AUTO BODILY INJURY (PeraWdsnU S ALL OWNED SCHEDULED AUTOS X AUTOS 4CC295393 -4 /31/2014 /31/2015 HIRED AUTOS " NON-OS S M"w Mff"rds S 5_.020 UMBRELLA LIAR OCCUR �- FCf�`.M rX�r:l1RRENr.E ...._ S EXCESS LIAN CLA MS•MADE 11 AGGREGATE S DED Rcrc E12H S S WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN t�,ev �•• ANY PROPRIETORIPARTNERADMCUIWE O"ICERMEMBER EXCWDED9 I N I A F.L. EACH ACCIDENT S E.L. DISEASE - EA EMPLOYEE S (Mandatory In NH) &TOMON ERATIONS Wcw E.L. DISEASE - POLICY LIMIT S CrE'SCTyIPTION'OF OPERATa(3tS I LOCATIONS r vElecLSIR (Attaa h ACORD istp Addpl rW Remarks Sarre, 9 more span a kr rarplrlrod) Additional Insured City of El Segundo, its officers,officlas, oz4ployaos, agents, and volunteers. Event Date May 2, 2015 Hometown Fair on Main Street in el Segundo. CIE TIFICATE HOLDER CANCELLATION City of El Segundo 350 Main Street El Segundo, CA 90245 ACORD 26 (201 INS025(aAtcnoi SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORCIED REPRESENTATIVE 1D 1I155.2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 3/10/15 Certificate of Exemption from Workers Compensation Insurance To: City of El Segundo From: Elite Special Events Subject: Sole proprietor, partnerships, closely held corporations with no employees Please let these memorandums 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. Contractor Signature: Contractor Name: