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PROOF OF INSURANCE (2016) CLOSED"�" � � 1 1 CERTIFICATE OF LIABILITY INSURANCE DATE (MMI °DIYYYv j� 7/23/2015 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( "es) 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 CONTCT Stephanie Weiss Specialty Insurance Agency NAME'- ................................................. �..........................................................................................__......................................... ............................... c its s4 esa, 4257 P Y g Y PHONE FAX,... ..... Performers of the U.S. 'Aac "° FYn 08 IA FAX N i 7 5- E MAIL . ............. .. P.O. Box 24 ADDRESS Pl(Ylnsuranceagency com New Richmond, WI 54017 INSURERS) AFFORDING COVERAGE NAIC # INSURER A: Evanston Insurance Company 35378 INSURED Eric R. Greenberg INSURER B: dba Liberty City 18560 Vanowen Street, Unit 14 INSURER C: Reseda, CA 91335 INSURER D INSURER E: 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. SR _... ..._....., ........ ..... SrSL uew iY ,,,, ,,,,,,, ,,, .... ......,,, PMI[aIC,�]V�'1 ....... ..,.,.,,n,n,,..._-....,,,,.,, ....... ......_______._.._.___ TR TYPE OF INSURANCE ,, NUMBER POLICY FR (MM f! 11 %Cr- ] /yyWl.,..... LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 3........, sAIGtAE "T�t�"D ..................... ®. 00,000 X COMMERCIAL GENERAL LIABILITY pRFMis_FC IFA ���,�RP 1 $ CLAIMS -MADE X OCCUR .. M�.,.. �... �...��.,:��......��....... ...$ ..............---.......... ...........�..m.m.3... E EXP (Any one person _ A X X 2CN0129 -2490 04/25/2015 04/24/2016 PERSONAL &ADVINJURY $ 1,000,000 .....................-.................................... .....................�......... ..................... ............2..000..000.....,. .................................. ..........- _______..__________ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER. PRODUCTS COMP/ OP AGG $ 2,000,000 X POLICY PRO. LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE &. WT (Ep accident) $ BODILY INJURY (Per person) $ ANY AUTO ALL OWNED - SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS PROPERTY DAMAGE $ NON -OWNED HIRED AUTOS AUTOS 113— cid—h UMBRELLA LIAR OCCUR ............. EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGR EGATE $ $ DFn RFTFNTION $ WORKERS COMPENSATION WC STATU- OTFi- AND EMPLOYERS' LIABILITY 71YANY OFFICER/MEMBER EXCLUDED? NIA - �IEA � in NH�PARTNER/EXECUTIVE EMPLOYE(Mandatory E L DISEASE $ If yes, describe under .. ......... ......... ...._ ............. .............� DESCRIPTION OF OPERATIONS below E L DISEASE POLICY LIMIT J $ A BUSINESS PERSONAL PROPERTY,, AGGREGATE $ INLAND MARINE DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) PERFORMER IS A NAMED INSURED AS A MEMBER OF PERFORMERS OF THE U.S.: Eric R. Greenberg dba Liberty City Additional Insured: The City of El Segundo, its officers, officials, employees, agents and certified volunteers are named as additional insured, but only insofar as the operations under this contract are concerned. Fax: 818- 344 -6108 Email: libertycityeric @aol.com Attn: Julie Todd CERTIFICATE HOLDER CANCELLATION City of El Segundo 350 Main St. Room 5 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE El Segundo, CA 90245 -3813 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE JjU ©1988 -2010 ACORD CORPORATION. All rights reserved„ ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD COMMERCIAL GENERAL LIABILITY POLICY NUMBER: 2CN0129 or 2CN0130 INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED This endorsement modifies insurance provided under the following COMMERCIAL GENERAL LIABILITY COVERAGE FORM PRODUCTS /COMPLETED OPERATIONS COVERAGE FORM LIQUOR LIABILITY COVERAGE FORM PROFESSIONAL LIABILITY COVERAGE FORM Please refer to each coverage form to determine which terms are defined. Words shown in quotations on this endorsement may or may not be defined in all coverage forms. SCHEDULE Person or Entity: Any person or organization to whom you are obligated by valid written contract to provide such coverage. Additional Premium: $ (Check box if fully earned.) Included WHO IS AN INSURED is amended to include the person or entity shown in the Schedule above as an Additional Insured under this insurance, but only as respects negligent acts or omissions of the Named Insured and only as respects any coverage not otherwise excluded in the policy. Our agreement to accept an Additional Insured provision in a contract is not an acceptance of any other provisions of the contract or the contract in total. When coverage does not apply for the Named Insured, no coverage or defense shall be afforded to the Additional Insured. No coverage shall be afforded to the Additional Insured for injury or damage of any type to any "employee" of the Named Insured or to any obligation of the Additional Insured to indemnify another because of damages arising out of such injury or damage. All other terms and conditions remain unchanged. MEGL 0009-0104 11 Includes copyrighted material of Insurance Services Office, Inc. Page 1 of 1 with its permission. July 21, 2015 To Whom It May Concern, Liberty City contracts our various performers on an "as needed" basis for individual events rather than hiring individuals as employees. All of the performers are independent kf\./ contractors responsible for their own taxes. Since we have no employees we do not provide workman's compensation. 18560 Vanowen St. #14 • Reseda, CA 91335 • office: 818 - 344 -6929 • fax: 818 - 344 -6108 www.Iibertycityent.com SDA �t (HEREIN CALLED THE COMPANY) UNITED STATES HOME OFFICE SAN DIEGO, CALIFORNIA NONASSESUBLE POLICY PAGE i FAMILY COMBINATION AUTO POLICY OFFER TO RENEW * * EFFECTIVE NOV 5,14 YOUR COVERAGE EXPIRES ON NOV 5,14. TO KEEP YOUR POLICY IN FORCE, PAYMENT MUST SE RECEIVED BEFORE NOV 5,.14. IF PAYMENT IS RECEIVED ON OR AFTER NOV 5.14, YOUR POLICY BECOMES NULL AND VOID.. REMEMBER THERE 1 NO GRACE PERIOD AND NO FREE INSURANCE. PLEASE MAKE YOUR PAYMENT NOW. FA 7297964 NOV 5,14 NOV 5,15 1 2A1A .M.STANDARDTWEAT THE ADDRESS OF SIB- 344 -8339 y y THE NAMED INSUREO AS STATED HEREw ERIC GREENBERG WAWANESA GENERAL INSURANCE CO 18560 VANOWEN ST #14 9050 FRIARS RD_, SUITE 101 RESEDA CA 91335 SAN DIEGO CA 92108 -5865 TELEPHONE 1- 800 - 640 -2920 DESCRIPTION OF OWNED VEHICLE(S) VEH YR MAKE- DESCRIPTION VEHICLE I.D. NO. COMPUTER IDENTIFICATION 1 09 HONDA,FIT JHMGES8229SO59233 710P1000O45MUPGlM OOYII111293213352 2 13 HYUND,ELANTRA KMHDH4AE4DU952103 314PI000049FUPGGM ODYII111293213352 INSURANCE IS PROVIDED ONLY WHERE A PREMIUM IS SHOWN FOR THE COVERAGE, COVERAGE AND LIMITS OF LIABILITY PREMIUMS SEE POLICY FOR COVERAGE DETAILS VEHICLE 1 2 A BODILY INJURY LIABILITY 15,000 EACH PERSON /30,000 EACH OCCURRENCE 214.00 214.00 B PROPERTY DAMAGE LIABILITY 5,000 EACH OCCURRENCE 158.00 158.00 C MEDICAL PAYMENTS 5,000 EACH PERSON 55.00 55.00 D COMPREHENSIVE (EXCL. COLLISION) 500 DEDUCTIBLE 19.00 26.00 E COLLISION 500 DEDUC'T'IBLE 273.00 364.00 G UNINSUREO /UNDERINSURED MOTORIST PROTECTION 30,000 EACH PERSON /6-0,000 EACH OCCURRENCE 58.00 58.00 I UNINSURED 140TORIST- COLLISION DEDUCT WAIVER 14.00 14.00 TOTALS BY VEHICLE 791.00 889.00 TOTAL POLICY PREMIUM: $1,680.00 PREMIUM DISCOUNTS AVAILABLE: MULTI -CAR; GOOD DRIVER; THEFT RECOVERY SYSTEM; MATURE DRIVER COURSE; DRIVER TRAINING DISCOUNT; PERSISTENCY DISCOUNT PREMIUM DISCOUNTS APPLIED: MULTI -CAR; GOOD DRIVER; PERSISTENCY DISCOUNT APPLICABLE FORMS FORM 0 VEH FORM M VEH FORM N VEH FORM N VEH FORM M VEH FORM 0 VEH PAP 09/09 WAPRVC 01/14 I lciO CONTINUED ON NEXT PAGE .a . , Keep this portion for your records Return this Portion with your payment NON - ASSESSABLE POLICY PAGE 2 FAMILY COMBINATION AUTO POLICY OFFER TO RENEW * * EFFECTIVE NOV 5,14 YOUR COVERAGE EXPIRES ON NOV 5,14. TO KEEP YOUR POLICY IN FORCE, PAYMENT MUST BE RECEIVED BEFORE NOV 5,14. IF PAYMENT IS RECEIVED ON 09 AFTER NOV 5,14, YOUR POLICY BECOMES NULL AND VOID.. REMEMBER THERE IS NO GRACE PERIOD AND NO FREE INSURANCE. PLEASE MAKE YOUR PAYMENT NOW. FA 7297964 I NOV 5 , 14 1 NOV 5, 15 ice, Ate• STANDARD TIME AT THE ADDRESS Of 1 818-344-8332 a THE =ED MURED AS STATED HERWIM j ERIC GREENBERG WAWANESA GENERAL INSURANCE CO 18560 VANDWEN ST 014 9050 FRIARS RD., SUITE 101 RESEDA CA 91335 SAN DIEGO CA 92108 -5865 TELEPHONE 1- 800 -640 -2920 DRIVER NANE(S): GREENBERG. ERIC R KLOTZ, ELLEN L MIMI= Keep this portion tor your records Return this portion with your payment ICIE MExrltACwTOM CARD F Poercv Nr�a� Fe ., 77_Ae7%A SAM MW GLL�O.WA wren ERIC GREENBERG .....a 18560 VANOWEN ST N14 ..a Adn.ass RESEDA CA 91335 ``Rama 11 0,5 14 11 Q5 15 r__..._ Axe varia.E I TIIWIC�aT�N � vEAwitit 09 HONDA JFMGERS229SO59233 b vrce c.owum ON ne.ouc+Moen T"tM w UAIMn was woa de„. LAW O,'k'. wY~''A.!W. Mmmt.* tm 110w, — +,#wk,Mr� wsMlw.ltE +Ei�CIE MEMTNC�tWpa �:>•ND „� ►OIICY �W IMMilMP FA 7297964 ERIC GREENBERG 1SS60 VANOVEN ST A14 RESEDA CA 91335 11 05 14 1 i 05 15 YEANrMAKE VEHICLE 10ENTIFICATION WJMOM � .13 FIYEIND a �e..�KAB-DF14AE4DU9 52103 .. _ .._{ covenaE . wow ®ev ne .oaK.�•.�rt-WS n�.w.rr w�srr ur.rs .IaRe67 ea..ww sm.om m"monom amWavom=x .wt *,tea- 051,07,120"'11Sk r,,m;x NONE GREENBERG w ERIC RALPH 18560 VANOWfiN APT 14 RESEDA, CA 91 aaa+�a Y�4au,Nil'4��p'�a�'�'il,y r a l' R CORR 4k'Nb Oroyll N tkl5 mEw m "Oo soda W:ov'was SAN OU2V2013