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PROOF OF INSURANCE (2015) CLOSED. YYY) C CERTIFICATE F LIABILITY INSURANCE 5 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 policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terns and conditions of the policy, certain policies may require an endorsement, A statement on this certificate doss not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER IIAfd E HCC Specialty fa/9' N F t, _m 6 mat lslia., 401 Edgewater Place, Suite 400 ADDRESS .PRODUCER, Wakefield, MA 01880pr.±'tt! ...,_ ...__ As FORDING COVERAGEm. ..Q._..... INSURERS) _.,..m m,.m ...m_ - ,._ ,.. ..,. W . tC � ItJitmate Jam Band _ - -.. -- ._. .._........- .�w��, IFISURERwB . mm United States Fire llnsurrance Company, ._. 21311 ._ ..a 1001 W. Lambert Road #287 IHSURERc . ,, W ._.... La Hambra, CA 92833 INSURERn iNSURERF: _ COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY T14AT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REOUIREMVNT, TERM OR CONDITION OF ANY CONTRACT Oil OTHER DOCUMENT WITH RE'SP'ECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR 1AAY PER -FAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREw IS SUB IECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEE14 REDUCED BY PAID CLAIMS, m1sR�'. -:. ...,.._ . .m .,.. .,.. . ...... ..... ...... m__.:n_ _.rc..._ AO'b1:" R ." _. POLICY (YYY ..- _.._.. POLICY CX LIMITS I Tn TYPE OF INSURANCE � nicra � vruo POLK:Y HUMBER fMf„II'DOtYYYY) Cf!'pD�,I�",� GENERAL LIABILITY A C (OCCURRENCE S 1,000,000 GENER 7tMOGE TO RCNiEDCiO 000 A COMMERCIAL GENERAL LIABILITY SELQ1 Q338706 0911112015 111031241$ DRFIU15F4 tFa nrnv nrnl s I CLAIMS- MADE ,... OCCUR En cvo re t c FJ QQ� X H st Liquor PERSONAL & ADV INJURY 1,000,000 B G£ Nil )i�dpCaAEXpenAPPLIESPER:�^.,�� � US43834$ 09!11!2015 1110312015 PRdDtJCis AGGREGATE 2.000,000 sw.m ,. 10000OQ.' X POLICY ` " Ph LOC N $ iE T' _ AUTO accident) LIMIT I (Ea a$INED SINGLE AUTOMOBILE LIABILITY COMBINED ANY AUTO BODILY k4 TURY (Par person) 'i _ ,_.__ ..,.. _ w.. . ALL OPINED AUTOS _ _ .... ...- __.. � .. W _ BODILYINJURY {Peraaldanlj $ SCHEDULED AUTOS PROPERTY DAMAGE � HIRED AUTOS (Per accident) NON-OWNED AUTOS OCCUR EAf7i OCCURRENCE $ CLAIMS MADE A� .. '' mm GGAEGATE 5 EXO£ELLALIAB V 55LIAB DEDUCTIBLE „w.... 5 $ .�. .. ,. WORKERS COMPENSATION I. AND EMPLOYERS' LIABILITY YIN TnaY t IlAlrs i 1 - ANY PROPRIETOR+PARTNER/EXECUTIVE E.L EACH ACCIDENT $ OFFICERRdEMBER EXCLUDED? (Myandatory in NH) E.L. DISEASE- EA EMPLOYFF F$ Des d "iiao t"der ,ATIONS i>nlaet _ E,,L DISEA5,E POLIC,.. ".,_._ _.... .....,. ,...,�_, «.._. Y LIMIT S DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES (Attach ACORD 701, Add'ntonal Remarks Schsdule, If more space is required) The Ceniricale HoWar is added as Additional Insured vnih respects to our in�red's dperatlons only This insurance is primary and norrcom6butory as required by wdttarl contract, This coverage is with resped to Et Segundo Hallo uaen Frolic everd to be held 10/311201 5 - 1013V2015 at City of El Segundo El Segundo CA City of El Segundo, its officers, officials, employees, agents, and volunteers 350 Main Street El Segundo, CA 90245 SHOULD ANYOF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTAT ACORD 25 (2010105) @'1988 -2010 ACORD CORPORATION, All rights reserved. POLICY NUMBER: 10336706 COMMERCIAL GENERAL LIABILITY CG 20 26 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL AL 1 S E — DESIGNATED PERSON I i 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, "4.. Information required to complete this Schedule, if not shown above, will be shown in the A. Section 1[ — 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 contractor 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 'I P 0 Box 50660 Phoenix, AZ 85076 ORIGINAL AUTO POLICY DECLARATIONS NAMED INSURED: Bobby Johnson 100-i W Lambert Rd Slox 287 La Habra. CA 9OC-31 dd - s he insured oroc, n6palky gai agee, at ltl.is a,�,ve z-, , e, is PM 1-wd , , This Declarations page alOng W h "POlicY Provisions" and any other appilcable endorsements l es your polic - Ex _-o Joh_nscm -4 Desc rip lion, ot fnsursa m-op arly. Annual k4lies Use LU, e, Yee a r ma-ef Modei WIN) �,3ymb,,ai '_Per ona FC.P.D ESClUE Ij �J 2 3, S C G ID dot 1 H C' I- "A S Mon 1 1.0 77 7 7r), _�v,%4 i age is prrivided onty ,Vl,e.re a prernium 1 W 411 co �rnp 2- ell e la', Va- cv Fee Fraud Fee: 8 C, 0 C4 1111I poise y at �iiikl r ISZAMI: Iota Ch Information regarding any increase in pren-kim due to the invo%Wemont in any charg cable accidents or convii,.0ons C11.1 be obtained upon request by contacting Legacy Customer Service. (C�,C 381.1 & 48�9) k -our Ar-,r4 01, 2015 -n�r Signed: fDate ORIGINAL MURED COPY S J, 4 0� c -, - Iota Ch Information regarding any increase in pren-kim due to the invo%Wemont in any charg cable accidents or convii,.0ons C11.1 be obtained upon request by contacting Legacy Customer Service. (C�,C 381.1 & 48�9) k -our Ar-,r4 01, 2015 -n�r Signed: fDate ORIGINAL MURED COPY September 30, 2415 Attn: City of El Segundo Re: Worker's Compensation 16V i, Bob Johnson, band member of the Ultimate Jam Band certify that all. band members are independent contractors. Bob Johnson Date' °d