Loading...
PROOF OF INSURANCE (2015) CLOSEDbize CERTIFICATE OF LIABILITY INSURANCE D04 /16 /2015Y' 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(le) must be endorsed. If SUBROGATION IS WAIVED, sub)ect 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 NAME: HCC Specialty /eHO � NE 1� � AC Not SIC `FJ .. 401 Edgewater Place, Suite 400 ADDRESS Wakefield, MA 01880a /t!gIIIp.t........ 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 ,.., INSURER(S) AFFORDING COVERAGE NAIC # -- -- - - - - -- ......... ...... INSURED INSURE....... RA: New Hampshire Insurance Comr)anv 23841 The Scott Whyte Band .......... INSURERB: .. ._ .. a. United States Fire Insurance Company 21113 12 Bridgeport LIMITS _ Manhattan Beach , CA 90266 INSURERC: INSURER D .......... . ... �,............ ,.., .............. ........ .............,. - - - -- X INSURE RE: ............ ......., ..... , .. . . . ....... . ...... 04/16/2015 08/12/2015 - DAA'rMAGEG To FENTEO""'"°'" 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. 1NSR _ww— ,..,... ........ ............A.....- POLI�YNUMBER ...� ". "'.i+"O"CYC"YEF'F"-_._ POLICYEXP ----- LTa TYPEOFINSURANCE iusR (MM /DD/YYYY) rMM /DD(VVVV1 LIMITS GENERAL LIABILITY $ 1.000.000 A - - - -- X SEL017253301 04/16/2015 08/12/2015 - DAA'rMAGEG To FENTEO""'"°'" X COMMERCIAL GENERAL LIABILITY PRFMIRFR (Fa me ....­ .) $ 300,000 ....... __ -MADE OCCUR CLAIMS MFD _F.P _ ..(�An,.v . ..a_a m ... arnn l _ ..R r ,.. mm 5000 X Host Liquor PERSONAL & ADV INJURY ..........,,,._ ..................... ..........__.......__....,,,,., ..m. $ ,w....,.mm .._....,.....,,..............,� 1.000.000 _..wwww ......_ X Medical Expense B US433141 04/16/2015 08/12/2015 GENERAL AGGREGATE $ 2,000.000 GEN'L AGGREGATE LIMIT APPLIES PER. PRODUCTS COMP /OP AGG $ 1 ,000,000 X POLICY D pR0• —` LOC JEG''T $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO ...... ...- �..,�..,�..,�. .�.,.,. ..n, .,,,,., BODILY INJURY (Per person) M.,...... ,... $ ........ —». ALL OWNED AUTOS _.._ _ ._. .....m....,....�..,....,..�,m BODILY INJURY (Per accident) ....,.n..,. $ ...... ........�... SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS (Per accident) $ NON-OWNED AUTOS ___ . ... ...................... .....__ $ $...._W.. UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE Lj AGGREGATE $ ........ DEDUCTIBLE .,.. ,..., ....,�-- - - - - - -- ----- $ ........, ............._...... ... RETENTION $ $ WORKERS COMPENSATION n-Y," AND EMPLOYERS' LIABILITY Y / N I , To. ANY PROPRIETOR/PARTNER /EXECUT VE EXCLUDED? E L EACH E. T mm. mm �mmmmmm $ m����mmm mmm ^„ m (Mandatory in NH) E „L„ DISEASE E - EA EMPLOYEE, $ If yes, describe under DESCRIPTION OF OPERATIONS below F , DISEASE POLICY LIMIT R DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) The Certificate Holder is added as Additional Insured with respects to our Insured's operations only. This insurance is primary and non - contributory as required by written contract.. This coverage is with respect to El Segundo Concert Series event to be held 8/9/2015 - 6/9/2015 at Library Park El Segundo CA City of El Segundo, its officers, officials, employees, agents, and volunteers 350 Main Street El Segundo, CA 90245 L.AIVL.tLLA I IUIV 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 ACORD 25 (2010/05) ©1988 -2010 ACORD CORPORATION. All rights reserved. POLICY NUMBER: 17253301 COMMERCIAL GENERAL LIABILITY CG 20 26 04 13 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 Additional Insured Person(s) Or Organization(s): City of El Segundo, its officers, officials, employees, agents, and volunteers, 350 Main Street, El Segundo, CA, I Information required to complete this Schedule, if not shown above, will be shown in the Declarations. I A. Section II — Who Is An Insured is amended to include 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 omissions of those acting on your behalf: 1. In the performance of your ongoing operations; or 2. In connection with your premises owned by or rented to you. However: I 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: 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 endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. CG 20 26 04 13 0 Insurance Services Office, Inc., 2012 Page 1 of 1 Other Household Driver(s) In addition to the Principal Driver(s) and Assigned Driver(s), your premium may be influenced by the drivers shown below and other individuals permitted to drive your vehicle. This list does not extend or expand coverage beyond that contained in this automobile policy. The drivers listed below are the drivers reported to us that most frequently drive other vehicles in your household. F WILLIAM WHYTE KAREN WHYTE Principal Driver & Assigned Drivers For each automobile, the Principal Driver is the individual who most frequently drives it. Each driver is designated as an Assigned Driver on the household automobile that he or she most frequently drives. a ��Nm. � �4t! �.. � w.,� iU� 0"Jil " Your premium may be influenced by the information shown for these drivers. ;l a OV,111 M A G E ll''�4II j IV II II'IVI II Ir S See your policy for an explanation of these coverages. 250,000/500,000 Property Damage 100,000 $267.16 D 500 Deductible Comprehensive $28.45 G 500 Deductible Collision $170.60 Uninsured Motor Vehicle _ Bodily Injury 30,000/60,000 $17.82 U1 Uninsured Motor Vehicle _ Property Damage $2.35 If any coverage you carry is changed to give broader protection with no additional premium charge, we will give MSCOLflWTS These adjustments have already been applied to your premium. Line you the broader protection without issuing a new policy, starting on the date we adopt the broader protection. Multicar Driving Safety Record r' California Good Driver ✓ Policy Number. 277 5440 - 1316 -75G Page number 3 of 4 Prepared January 12, 2015 a Tune 15, 2 015 Re: Worker's Comp independent contractors. w� f i attire