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PROOF OF INSURANCE (2015) CLOSED/"'YaL C) L./® � CERTIFICATE LIABILITY INSURANCE DATE (MM /DD/YYY`0 1 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 Western Sentry Insurance Brokers CONTACT Jerry Glenn PHONE 805- 577 -8522 F 888 -875 -2902 A/C, No, AIC No 4212 E Los Angeles Ave #9 ADDRESS westernsentry@gmail.com 10/25/14 PRODUCER CUSTOMER ID: INSURERS AFFORDING COVERAGE NAIC # Simi Valley CA 93063 INSURED INSURERA: The American Insurance Co / FFIC $ 10,000 Michael Bell INSURER B: dba: Bell Event Services INSURER C: GEN'L AGGREGATE LIMIT APPLIES PER: ✓! POLICY ! ECOJ !, 1 LOC 3206 Galli St INSURER D: INSURER E: Hawthorne CA 90250 INSURER F: COVERAGES CERTIFICATE NUMBER: 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. 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 MMIDD MM /DD LIMITS A GENERAL LIABILITY ✓! COMMERCIAL GENERAL LIABILITY ._ I CLAIMS -MADE !' li OCCUR X 8H5ABC80900222 10/25/14 10/25/15 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES Ea occurrence $ 100,000 MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: ✓! POLICY ! ECOJ !, 1 LOC PRODUCTS - COMP/OP AGG $ 2,000,000 AUTOMOBILE LIABILITY _ ANYAUTO ALL OWNED AUTOS -. SCHEDULED AUTOS HIREDAUTOS NON - OWNEDAUTOS COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ UMBRELLA LIAB OCCUR EXCESS LIAB CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ _ DEDUCTIBLE !, RETENTION $ $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER /EXECUTIVE OFFICER /MEMBER EXCLUDED? _, (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N/A WC STATU- OTH- TORY LIMITS I 11 ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ 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 perAB9189 -8 -07 laKI lhll:Alt r1ULUtK % LAN%,r_LLAI IUN City of El Segundo 350 Main St Rm 5 El Segundo CA 90245 -3813 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Certified Signature------------------------ Jerry Glenn @ 1988 -2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD Progressive P.O. Box 94739 Cleveland, OH 44101 1- 800 - 895 -2886 Certificate Holder THE .C.ITY .O .E.L .SEGUNDO . 35 MAIN ST EL SEGUNDO, CA 90245 Insured ............................... MICHAEL) BELL BELL EVENT SERVICES 531 MAIN ST #228 ELSEGUNDO,CA 90245 Policy number: 04315274 -5 Underwritten by: Progressive Express Ins Company March 3, 2015 Page 1 of 1 Agent .............................. PROG 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 LocationNehicies /Special Items Scheduled autos only Certificate number 06215GSM274 ........ . ... .............. .. ........... I ... .. Policy Expiration Date: Aug 21, 2015 Limits .............. $750,000 Combined Single Limit Please be advised that the certificate holder will not be notified in the event of a mid -term cancellation. )Pli-t- Form 5241 (10102) Policy No, ABC80900222 This Endorsement Changes The Policy. Please Read It Carefully, 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. Blan)XI Additional Insured Section It - U.1ility Cor=ps, P=t L Who Is An Imured, It= 2 is Wncrulcd to inicbmit: i I. Any p:mn or orsn 17-dian that you art rr- rluiled by a ' i milen ift=td coittrad to include as an insured, subject to J, of the fallowing provisio.=. Cov=_g is limited to dicir Eabffi*, xir^- ing out of (a) tht oummhip, rul:'Itcaance or use of that part of the pfatnLcl, or ian-d nwnzd by, rented in, or (cased to you; or (b) your onploing optruxions PC.rfonued for that inured; or V (C) that irmured's financial central a, Yotu or (d) the maintenance, op,--ation or Ice by you or quip-mern Itasod to you by such pcan-n(s) at a-pni7ation(s); ar (C) a state or publical subdivision pts- Mir issued to you. (2) Co,trog. dots .01 apply to any eecur- rmCC ., oflenrt: (a) which tank Place bdua, flo: CIx. cution of, or wbstclutot to 11r: compic I inn or exr=lion of, tht written Insured Contract. or (b) wkuch takes place afkcr yov Leas. to be Z tenant in that r=outtSL 13) With respect to axchitccts, tog .oncrts, or 5urveyors, covmec dots not apply to lWily Injon, property Darn2gr, 11ce- sanal Injury or A6crtWng Injury wi±ing out of 1.11- rMilenng or the failure 1. .nd., any p,o-.siiooaI z=iats by or fz; you lncluhwg: The preparing„ approving, or '.16nr to prepare or aplmvc maps, draw- opiluom, rq=15, surxyl, dwqT onl=% th:irer', or trxcifr i- lions; and (b) Superisor•, iruptcfiun, or engi- neering =N=-S. I ate Additional n,.md widirtrnen; js atit-Ji:J polity that ..rne, . pecan or oq,mumfion as an insured, then Ibb cuvragt tl-s out apply to that person or organimfion. 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 PRIES 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 EMPLOYER BELL EVENT SERVICES SC 531 MAIN STREET #229 EL SEGUNDO CA 90245 [JO4,CS] (REV.7 -2014) PRINTED : 03 -09 -2015 POLICYHOLDER COPY 6M 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. '7 Authorized Representative President and CEO EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. AAENDORSEMENT #1600 - BELL, MICHAEL U PRIES 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 EMPLOYER BELL EVENT SERVICES SC 531 MAIN STREET #229 EL SEGUNDO CA 90245 PO4,CSj (REV.7 -2014) PRINTED : 03 -09 -2015 CERTHOLDER COPY Sc P.O. BOX 8192, PLEASANTON, CA 94588 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 03-03-2015 CITY OF EL SEGUNDO SC CITY CLERK 350 MAIN ST EL SEGUNDO CA 90245-3813 GROUP: POLICY NUMBER: 9104391-2014-2 CERTIFICATE ID: 29 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 10 days advance written notice to the employer. We will also give you 10 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 110- EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT #1800 - BELL, MICHAEL J PRES SEC TRES - EXCLUDED. EMPLOYER BELL EVENT SERVICES SC 531 MAIN STREET #229 EL SEGUNDO CA 90245 [VM5,CS] (REV.7-2014) PRINTED : 03-03-2015 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: Sample Rate: Regular Premium equals: Surcharge: Additional Waiver charge: Total premium equals $5,000.00 13.30% ---------- $ 665.00 3.00% 19.95 $ 684.95 (665.00 + 19.95)