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PROOF OF INSURANCE (2015) CLOSEDDATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 06/15/2015 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: It the certificate holder is an ADDITIONAL INSURED, the pollcy(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 NAMEr. HCC Specialty PHONE etr u., f f�ielf 401 Edgewater Place, Suite 400 ADDRESS PRCYbUCIER ..... Wakefield, MA 01880 cusroMER10 #: ... - - - -- -- _......,,,,,. ........... .............. ........... ........ .... .... .... .�.�.�.�... .. .... PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO ..- INSURERS) AFFORDING COVERAGE NAIC # INSURED GENERAL LIABILITY INSURERA: ....--- -._ ........ ......... ,.................. New Hampshire Insurance Companv �_ .... 23841 Double Vision INSURERS: United Stay .a. States Fire Insurance ComDanV ­ 11 21113 287 East Bay Blvd. X INSURERC: SEL010334429 06/18/2015 Port Hueneme, CA 93041 AM rrPnrP1 PREMISES !Fa nrr� INSURERD: COMMERCIAL GENERAL LIABILITY INSURER E : ...... — . --------- OCCUR CLAIMS -MADE x �l INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: _ 5,000 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. 1h1" :.. .. ..............TYPEOFINS..... i1WUC .. ...... ...,.. POLICY NUMBER IMMOCIICYXYYI l PMM% DDYYYYI„..... ........�.......�...LIMITS.... ............... .... ....._..... GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X SEL010334429 06/18/2015 07/29/2015 AM rrPnrP1 PREMISES !Fa nrr� $ 300 000 COMMERCIAL GENERAL LIABILITY OCCUR CLAIMS -MADE x �l _ 5,000 X- Host Liquor PERSONAL & ADV INJURY $ 1,000,000 g( Medical Expense US435488 06/18/2015 07/29/2015 'GENERALAGGREGATE $ 2,000,000 N'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 1,000,000 X POLICY PROS. LOG J E7 a'i $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ - (Ea accident) ANYAUTO ..................................................._.-....._.....- BO DILY INJURY (Per person) $ ALL OWNED AUTOS .. .................... w. .,..,..,... BODILY INJURY (Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS (Per accident) $ NON-OWNED AUTOS $ ....$......... ­� ............. ............................... UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESSLIAB CLAIMS -MADE .... ...... AGGREGATE m_ .......,. $ DEDUCTIBLE , � ................................._. ........................................ RETENTION$ $............................. WORKERS COMPENSATION TC1RY I IMITS Ffd AND EMPLOYERS' LIABILITY YIN �L , ANY EXCLUDED ? ECUTIVE ....... � ry in NH) (Mandatory DISEASE A EMPLOYE• E.L. D $ If yes, describe under DESCRIPTION OF OPERATIONS helnw E L DISEASE POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Altach 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 in the Park event to be held 7/2612015 - 7/2612015 at Library Park El Segundo CA ,0\_J I CERTIFICATE HOLDER CANCELLATION City of El Segundo, its officers, officials, employees, agents, and volunteers 350 Main Street El Segundo, CA 90245 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: 10334429 COMMERCIAL GENERAL LIABILITY CG 20 26 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL ITIOI AL I S I ECG - 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, Information required to complete this Schedule, if not shown above, will be shown in the Declarations. 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: 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 © Insurance Services Office, Inc., 2012 Page 1 of 1 June 2, 2015 Attn: City of El Segundo Re: Worker's Comp Insurance I, Patrick J. McGrath, band member of Double Vision Tribute to Foreigner band, certify that all band members are independent contractors. ati�ut m ... ���, Interinsurance Exchange of the Automobile Club � r Automobile Policy Coverages •' Limits Renewal Declarations We are pleased to offer you a renewal for your automobile insurance policy To renew your policy, send at least the minimum payment on or before the due date Insurance is in effect only for the vehicles, coverages, and limits of liability shown on this declarations page and as set forth in the insurance policy and endorsements These declarations, together with the contract and the endorsements in effect, complete your policy If any change to your policy or to the information we have on file results in a premium decrease during the policy period, the Interinsurance Exchange reserves the right to apply any refund due to your outstanding balance g NAMED INSURED (Item 1 ) �..... .w_.w ...... -_ ...e.w. ......�w w..,..,.w __._ .__.... AUTO POLICY NUMBER CAA nQQ y 8071369 MCGRATH, PATRICK AND MCGRATH, RIKA 19942 ESTUARY LN HUNTINGTON BEACH CA 92646 -3921 -.- POLICY PERIOD (PACIFIC STANDARD TIME) POLICY EFFECTIVE DATE: 05 -15 -15 12:01 AM POLICY EXPIRATION DATE: 05 -15 -16 12:01 AM. VEHICLES Vehicle Vehicle Vehicle Comprehensive No Coverage No Coverage ANNUAL PREMIUMS Coverage is not in effect unless a premium or the word "included" is shown. ,.VEH......... �_ ...................................................................................................... .............................._ YEAR MAKE MODEL �.IDENTI CAT ................. .,,,,,,,,,,,,,,...,.._.,,,...�_ FI ION _..........___.m......., VEHICLE �m.... �..,, GARAGE ............ ANNUAL— ���ww� w.�.......��. VERIFIED SALVAGE NO NUMBER USE ZIP CODE MILES MILEAGE 2 2007 TYTA MATRIX SW STDIXR T 2 1 KR32E17C673033 PL .e PLEASURE ��2 92646 10 001 -12,500 ���� -� -�� ��- - -���� VERIFIED NO 3 2013 MAZD 31 SN=ORT JM1 BL1 UPBD1735497 COMMUTE 92646 15,001 -17,500 VERIFIED NO COVERAGES AND LIMITS Vehicle Vehicle Vehicle Comprehensive No Coverage No Coverage ANNUAL PREMIUMS Coverage is not in effect unless a premium or the word "included" is shown. . COVERAGES LIMITS OF LIABILITY Vehicle 2 Vehicle 3 Vehicle Vehicle Vehicle Liability (Pr �" I)dkf .._ _.... NO...:r'.Li a r No t tavw l a ........ ,�..No L ce tanr�ule W�No Covera�° e Uninsured Motorist Bodily Injury $250,000 each person/ $500,000 each occurrence $ 209 $239 Property Damage $100,000 each occurrence $ 121 $ 143 ;,gym..... Medical Total Prenliurn � ...... $ 473 $ 573 - ------------- -- ....... . - - -� Medical Payments $10,000 each person $ 58 $ 71 Physical Damage (Actual Casn Value unless otherwise stated less deductible) Vehicle 2 Vehicle 3 Vehicle Vehicle Vehicle Comprehensive No Coverage No Coverage No Coverage ,'No Coverage;. (Less Deductible) No Coverage No Coverage Collision No Coverage No Coverage ; No Coverage No Coverage (Less Deductible) No Coverage No Coverage Car Rental Expense (Pr �" I)dkf .._ _.... NO...:r'.Li a r No t tavw l a ........ ,�..No L ce tanr�ule W�No Covera�° e Uninsured Motorist ...._... ..� -.. _ _ .. ,........._ . Bodily Injury - $250,000 each person/ $500,000 each accident $ 85 $ 107 Uninsured & Underinsured Vehicles Uninsured Deductible Waiver No Coverage; No Coverage' Uninsured Collision - -. ---------- - - - - -- __ No Coverage $ 14 _. ..._.�._....- ..__...__... - - - - -- ... -..,.. ........... � .._...... _.. __...__.....� Total Prenliurn � ...... $ 473 $ 573 PREMIUM DISCOUNTS Please refer to the enclosed document entitled "Premium Discounts Applied to Your Automobile Policy " * If at any time you choose to pay less than the full balance outstanding, finance charges of up to 1.5 %® per month of the balance outstanding will apply as explained in your billing statements, which are part of these declarations. ** To see the annual mileage for your expiring policy, please refer to the "Notice of Annual Mileage" page contained in your renewal package. ......_ ............ _. m��.., ...................... .. m.. Coverage" indicates coverage not purchased Total Annual Premium* _ - -$ 1046 (Includes all applicable discounts ) Less Palicyholder Savings Dividend $ 136 Net Premium* $ 910 E2014101 PROCESS DATE 04 -07 -15 PLEASE ATTACH TO YOUR POLICY CAA02 A (SEE REVERSE) 040715