PROOF OF INSURANCE (2015) CLOSEDF DATE (MMIDDIYYYY)
4� � CERTIFICATE OF LIABILITY INSURANCE 03/03/2015
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 CONTACT Jerry Glenn
Western Sentry Insurance Brokers A/c, No, 805- 577 -8522 =AFTI N0 888- 875 -2902
4212 E Los Angeles Ave #9 I ADDRESS westernsentry@gmail.com
Simi Valley CA 93063
INSURED
Michael Bell
dba: Bell Event Services
3206 Galli St
Hawthorne CA 90250
INSURER(S) AFFORDING COVERAGE NAIC #
INSURERA: The American Insurance Co / FFIC
INSURER B:
INSURER C:
INSURER D:
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFYTHATTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVE 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.
INSR TYPE OF INSURANCE INSR WVD POLICY NUMBER MM /DD/YYYY tMM)DDfYYYYI, LIMITS
GENERAL LIABILITY
EACH OCCURRENCE
$ 1,000,000
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE OCCUR
V
OAMA F TO FINN „�
PREMISES Ea occu
rerson
$ 100,000
EX erson)
MED EXP (Any one p�
$ 10,000
,
PERSONAL & ADV INJURY
$ 1,000,0001
A
X
8H5ABC80900222
10/25/14
10125115
GENERAL AGGREGATE
$ 2,000,000
GEN'LAGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP /OP AGG
$ 2,000,000
. PROJW.
POLICY E'R LOC
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
(Ea accident)
$
ANY AUTO
BODILY INJURY (Per person)
$
ALL OWNED AUTOS
BODILY INJURY (Per accident)
$
SCHEDULED AUTOS
HIRED AUTOS
PROPERTY
(Per accident)AMAGE
NON -OWNED AUTOS
$
UMBRELLA LIA13 _
OCCUR
EACH OCCURRENCE
$
AGGREGATE
$
EXCESS LIAB
CLAIMS -MADE
DEDUCTIBLE
$
RETENTION $
$
WORKERS COMPENSATI AND
ON
EMPLOYERS' LIABILITY Y / N
Ar
TORY LIMITS ER
E.L. EACH ACCIDENT
$
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED? I
N/A
E.L. DISEASE -EA EMPLOYEE
$
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE -POLICY LIMIT $
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
Additional Insured: City of El Segundo, its officers, officials, employees, agents and volunteers As per AB9189 -8 -07
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
City of El Segundo EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH
350 Main St Rm 5 THE POLICY PROVISIONS.
El Segundo CA 90245 -3813 AUTHORIZED REPRESENTATIVE
Certified Signature-- -------- --------------Jerry Glenn
@ 1988 -2009 ACORD CORPORATION. All rights reserved.
ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD
Policy No, ABC80900222
This Endorsement Changes The Policy. Please Read If Carefully.
BLANKET ADDITIONAL INSURED -
SCHEDULED 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
and volunteers.
Blanket Additional Insured i
Section 11- Iistdlity Coverage, Pat L Who Is An
(e) a slate or political subdivision pet.
Insured. Item 2 is amended to inc� &
I;iut
mit issued to you.
L Anv Iw;rvon or a Ar�y.;wnuau'senn you are M.
(2) Coverage does not apply to any i rur-
quunal Ivy t w liticn inasar+,'reI' contract to include
rence or offence
as an insured, subject to all Qr the following
Provisions:
(a) which took place before II¢ exc.
(I) Covmge u limited to their liability axis •
cution a f, or subsequent to she
ing out oL•
Completion or expiration of, she
written Insured contract, nr
(a) l a wnerslup„ IYu.Iac4lancc m U!t
Of 01At I'at of the p gelnhvr vt wpna
(b) which takes place after you cease to
nu,11 4 hy, mAlled to of pQ'onI 14,
be a tenant in that promises
)' °iv'" 0.M1
(3) Willi respect to architects, enejtieers, or
(b) your ongoing operaliois performcJ
surveyors, coverage does nos apply In
for that insured; or
Iiodily Injury, Properly Damage, Pre•
sonal Injury or Adicrtiung Injury arivng
(e) that insured's financial control of
out of the rendering or the failure to
you; or
render any professional services by or for
you mclud'uig:
(d) the imaintenance. operation or use
by yiu of equipment leased to you
(a) The preparing, approving, or failing
by suds person(s) or organiration(s);
to prepare or appmte maps, draw•
or
ings, opirdous, reports, surmys,
clu llt omen, desills or specifica-
tions; and
(b) Supervisory, inspection, or engi.
neenng scivias.
!10.11:6 f Additional Insured endommen! is attached
pofey that specifically names a person o,
oqus'varion as an insured, (lien this covcrarfc dues
not apply to that person or organvmion.
CERTHOLDER COPY
SC
P.O. BOX 8192, PLEASANTON, CA 94588
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
ISSUE DATE: 03 -09 -2015
CITY OF EL SEGUNDO SC
ATTN: CITY CLERK
350 MAIN ST
EL SEGUNDO CA 90245 -3813
GROUP:
POLICY NUMBER: 9104391 - 2014 -2
CERTIFICATE ID: 30
CERTIFICATE EXPIRES: 08 -30 -2015
08 -30- 2014/08 -30 -2015
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 conditions, of such policy.
Authorized Representative President and CEO
EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE.
ENDORSEMENT #1600 - BELL, MICHAEL J PRES SEC TRES - EXCLUDED,
ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 03 -09 -2015 IS
ATTACHED TO AND FORMS A PART OF THIS POLICY.
ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2015 -03 -09 IS
ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME:
CITY OF EL SEGUNDO
Alk,
EMPLOYER
BELL EVENT SERVICES SC
531 MAIN STREET #229
EL SEGUNDO CA 90245
[JO4,CS]
(REV.7 -2014) PRINTED : 03 -09 -2015
WAIVER OF SUBROGATION NOTICE
Enclosed is your copy of a certificate of insurance on which the certificate holder
required a waiver of subrogation:
1. Please be advised that a waiver of subrogation requires that a 3% surcharge
will be applied by State Fund ONLY to the premium assessed on the payroll
of your employees earned while engaged in work for that certificate holder
who requested the waiver. (Note: if you have no employee payroll on that job,
then there is no charge.)
2. To apply the 3% surcharge, you must also agree to maintain accurately
segregated payroll records for employees engaged in work on job /s for the
certificate holder who has the waiver. The payroll records are subject to
verification by an auditor.
Example:
Payroll for job: $5,000.00
Sample Rate: 13.30%
Regular Premium equals: $ 665.00
Surcharge: 3.00%
Additional Waiver charge: $ 19.95
Total premium equals $ 684.95 (665.00 + 19.95)
Progressive
P.O. Box 94739
Cleveland, OH 44101
1- 800 - 895 -2886
e i i catte Insurance
Certificate Holder
... ...............................
THE CITY OF EL SEGUNDO
35 MAIN ST
EL SEGUNDO, CA 90245
Insured
..........
MICHAEL JBELL
BELL EVENT SERVICES
531 MAIN ST #228
EL SEGUNDO, CA 90245
l � s,T-4 J
Policy number: 04315274 -5
Underwritten by:
Progressive Express Ins Company
March 3, 2015
Page 1 of 1
Agent
....O...... ..
PR G COMMERCIAL
PO BOX 94739
CLEVELAND, OH 44101
This document certifies that insurance policies identified below have been issued by the designated insurer to the insured
named above for the period(s) indicated. This Certificate is issued for information purposes only. It confers no rights upon
the certificate holder and does not change, alter, modify, or extend the coverages afforded by the policies listed below.
The coverages afforded by the policies listed below are subject to all the terms, exclusions, limitations, endorsements, and
conditions of these policies.
Policy Effective Date: Aug 21, 2014
Insurance coverage(s)
Bodily Injury /Property Damage
Description of LocationNehicles /Special Items
Scheduled autos only
" Certificate number
06215GSM274
Policy Expiration Date Aug 21 2015
Limits
... ..... ... .....................„......,..,....... ,...a...�.�.........�,,.,....�.
$750,000 Combined Single Limit
Please be advised that the certificate holder will not be notified in the event of a mid -term cancellation.
P��--
Form 5241 (10/02)