PROOF OF INSURANCE (2016) CLOSEDkarv—ar
DATE IYY�
TE (MMfDD-!YYM
081812015
ACV CERTIFICATE OF LIABILITY INSURANCE A014orriri,45
-T—H[S-C—ERTIFICATE 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, subject to
1MPRTANT: If the certificate holder is an ADDITIONAL INSURED, the Policy(les) must be endorsed, If SUBROGATION IS WAIVED,
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
rortifir.Ata holder In lieu of Such endorsnem.,ent(sl-
RODUCER
IB Trans artatlon Ins Brokers PatdNE 81$- 246.2800_25 46D
25 West groadway, Suite 400 nAlc
EL
ilendale, CA 91204
ack Sandstrom
INARAER A
N-s—uRaolnlancl Empire Stages Ltd- _!NSURFR 11 1,
9567 Eighth Street lq.S U P E R IL'
Rancho Cucamonga, CA 91730-4504 lNSURCR 0 1
ANSURSR E '.
t AV PP I:.; ERTIFICATE NUMBER:
A C
INSURANCE LISTED BELOW HAVE
11-1
BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
t,---IIS IS TG CERTIFY THAT THE POLICIES OF
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
INDICATED, NOTWITHSTANDING
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 15 SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITION'S OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED By PAID CLAIMS.
--7—P60671
'TR TYPE OF INSURANCE pn� iry NUMBER
P LIMITS
L��CH OCCURRENCE 5 2,000,001
X COMMERCIAL GENERAL LIABILITY
'100100i
CLAIl`4S4,%0E rx-11 OCCUR X X
P 1�,!5-ELS fE�
P!�*.s 5,00,
_(Anyor-e
P E R S 0 N &L & ACY-I -5 21000,00,
GENERAL AGGREGATE 2,000,06
L1_NLl, AGGREGATE LIMFT APPLIES PER
111 I--1 PRO- F-7
DUCT$ � COMPIOP ACG S
�UTOMOBILE LIABILITY
--,,T;
~
COMBINEOTI-N-U-1 70T 5,000,00
0913112015 0813112016 BODILY)t.-JURY (Pw, pe,
A ANY AUTO X X OA`167040*13
r5O
ALL OWNED x S�^.qEDULED
AUTI AUTOS
NON-OWNED I
LY INJURY fil�lrai�
PROPERTY0 4A
X j HIRE-ALF-10S z
L.
UMBRELLA LIAR OCCUR
EACH OCCUPRENCE
E XCESS LIAB 1 CLAIl
7- n
±GGREr0ATt__
DED R'ETENTIDN5
OTH.
�Llraao-SiB�MPOSA;T%N
LIA1311,IT'y
AND EMPLOYERS YIN
ANYPRO -RET0PJPARTl1ERr=-XECL-1 NEj WA
Exlcwott, ?
E-A EMPLOYEE S
CFFICEI"AE�.ISCR
I(Mmdatory;n
E.L DISE.ASE -
NH)
SrL DISEA-Se - Poocy L11,11 { S
DEsmunON OF OPERATIONS I LOCATIONS t VEHICLES EACORD 101, Addition . Ai Remarks Schedule, may be attached If more spate is required)
rHE CITY OF EL SEGUNDO ' ITS OFFICERS OFFICIALS EMPLOYEES AGENTS AND
/OLUNTEERS ARE ADDED AS ADDITIONAL INSURED 6UT ONLY TO YHE EXTENT
THAT' THE CERTIFICATE HOLDER IS HELD LIABLE FOR THE CONDUCT OF THE NAMED
NSURED. ",WAIVER OF SUBROGATION APPLIES" "THIS POLICY IS PRIMARY AND
iON -CONTRI SU TORY"
0000000
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PnOVISIONS-
City of El Segundo Ji I
Parks & Recreation r, AUTHORM REPRESENTATIVE
c/o City Clerk
360 Main Street Room 5 /91tes-
Atitindo, CA 902.'J4
Qig$I!l-2014 ACORD CORPORATION. All rights reserved,
ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
POLICY NUNIBER: GL156100 13
COMMIERCtAL GENERAL LIABILITY
CG 2010 04 13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL !NSURED - OWNERS, LESSEES OR
CONTRACTORS — SCHEDULED PERSON
ORGANIZATION
This endorsement mldifieu insurance provided under the `o lo,, ing:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person(s)
Or Organization(s)
Locationts) Of Covered Operations
CITY OF EL SI.S:GiINDO
ITS OFFICERS, OFFICL LS, ENNIPI- 0), LFS
AGENT S k ND VOL UNTEE RS
350 Ni A t N S "t R E; T
ESL SEGUNDO" , CA 9024-5
Information required to complete this Schedule, if n�ot shown above; twill be shown in the Declarations,
A. Section If – Who Is An Insured is amended to
2. If coverage provided to the additional insured is
include as an additional insured the person(s) or
required by a contract or agreement, the
organizatior,(s) shown in the Schedule, but only
insurance afforded to such additional insured
With respeck to liability fog :IJCSdiiy injury", "property
tdiif tc�t tie I;rcacrer tl�ai� tl.at whirl, you are
damage" or "personal and advertising injury"
required by the contract or agreement to
caused, in whole or in part, by:
provide for such additional insured.
1. Your acts or omissions; or
2. The acts or omissions of those acting cn your
behalf:
in the performance of your ongoing operations for
the additional insured(s) at the location(s)
designated above.
However:
1. The insurance afforded to such additional
insured only applies to the extent permitted by
law; and
CG 2010 0413 0 Insurance SInrvices Office, Inc.. 2012 Page 1 of 3
B. 10r +ith respect is the insurance a1#orded to these
additional insureds, the following additional
exclusions apply:
This insurance does not apply to "bodily injury" or
„property damage" occurring after:
1. All work, including materials, parts or
equipment furnished in connection with such
:pork, on the project (other than service,
maintenance or repairs; to be performed by or
on behalf of the additional insured(s) at the
location of the covered operations has been
completed; or
2. That portion of "your world' out of which the
injury or damage arises has been put to its
intend ®d use by any person or organization
other than another contractor or Subcontractor
engaged in performing operations for a
principal as a part of the same project.
Page 2 of 3 C) Insurance Services Office. Inc., 20121 CG 20 10 04 13
C. Wth respect to the insurance aftrde,'4 to these
'�61ditial insured' the fallowing "' is added to
additions! S,
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 Limit. of Insurance shown in the
Declarations.
CO 2010 07 04 (P ISO Properties, inc., 2004 Page 3 of 3 13
GU- 207 IATP)
(Ed-6--7P,)
5 kllk-
-h-'L,c- clido-ro-ement, eff-fect.--ive oj-� !,a,�a/3i-/-�,s at 121. 0.1 A.M. slU-ai"lda.-,.,d t`zltyae,forms
a part of Policy No.BA!57040#13
LMNCER INSURANCE COMPANY
by LAINTCER. INSURA1,7CE -COMPANY m.
Win=
of compatlyi
zl
4-
-----Ku—tized Represe'n Ea —ti 'v'- e-
t
ex-8tood and agreed that thre added as Add? tilonal
herejoy und
insured only with respects to operation o-f the named insured -,
Name CITY OF EL SEGLIM
1TS OFFICERS, OFFICIALS,
EMPLOYEES, AGENTS AND VOLUNTEERS
350 MAIN STREET
EL SEGUNDO, CA 90245
TSSUE DATE:
�..,.. INLAN -4 OP ID: OA
CERTIFI�,AT'E OF LIABILITY INSU W, aAr�IM�a,onlYYrt�
.THIS 6ERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO O .� � w,M.,._..w ......,.��
03 /Z�€t2D [ 5
CERTIFICATE GOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER RIGHTS UPON THE CERTIFICATE HOLDER. THIS
THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR P tODUCI -R, AND THE CERTIFICATE HOLDER,
IMPORTPaNT: I( the r,,Oltlerrte holder Is an ADDITIONAL INSuU EO, tho pDIICy(10S) must be or, orsed. It SUBP.OGATION IS WAIVED, subjrCt to
the terms and eondltlons of the policy, certain policies may require an endorsement A 5tatemant on "s cartiltcate does not confer rights to the
c
certificate holder In lieu of such endorsement y. GON c
e r X69 � � �gd� SITS
TII Trans ortatlon Ins Brokers PHONE �T � 818-246,4690 �
25 West roadwra , Suite 460 (�
Olendalo, CA 9120
Jack 6andstrorn _ uauaPlk l7d i P k FCSCIII MSS r ravo�aamr� NAIL it
WSUMAD Inland Empiro, Stages Ltd.
9567 Eighth Street
Rancho CuCalnonga, CA 917330 -1504
I INSURr rI f
0' f --- -RA gE S -�r r CERTIFICATE NUMBER, THE �rl5 i, Eo uSIO ANUMBER,
_ REVISION
THIS IS "!O CERTIFY i Hni THE POLIGIES OF INSURANCE LISTED 3ELOW HR'JE BEEN t5Sl1ED TO � 9qE ,?R THE POLICY PER01)
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 IIJSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS Or SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
YAtS )( s,® 6 ffir _� � w. w �NP LDIC i sPc r Iya oI ILD L Y vr t "b"t ub _. u rs
rr'E of INSURANCE 'rL10Y tuaeet %
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C -MtM nCIAL CE 4CAA: LIAZILITY rAvti 15xR Lh~. e 6 3
q CLAIM$44ADt I OCCUR
w 41E0 EKP'wta xro+w'src7l� .
PERSONAL &ADVINJUR'Y IS
g6 � " I L r C I tC 7 � O.;T ?L%E &LPOF.h � ^ @ 4 t E ti OD.' . ... U� +".. as
.....
b C:OM3'IWI AGG S _.
AU ,NdY IL i 0 8Qb "Y iN 4 Wt61, I.I__. .._
Y Pe r�rson, l S
TO1dOBILE L}ABiLITY
y BODILY Pasco u. S
N ALL QWtYF.0 3 t
auvos auras
I w 4
ra -
'r a Da, �
kI �D AUTOS AUTOS
UMERELLALIAB SACHOCCUFREN
OCCURRENCE �I
i
�S
A.. +'fsF"iLC.H.+i C � =
8 ^p ��..,..
'SN'ORKeRS COMPVNSATIO6xI ., "q,y1'1JI .. R I
A ANY
OFF' lY I dV ALIAS t7%1hF CIFFxVe Q 19 1 OIL rACH ICMD XT m... $ 1,000,
w - 1U 012416 ... _� .. -�_ �.�., _ .. mm.
�g1RssRP YCB.tCiCa� " "tlfAl t
X '15663014 14141._415
1,044,
I E:L. his3� f�CiP t tl L.IINb 1,440,
Ik r�;r �hplw,s III is Cr
all*ilriN I;MR;*FT'IOhN GrmrYe'sm
r e
DE5CRIPTION OF OPERATIONS I LOCAMNS 1 VEHICLES (ACORD iDt, Addltionul Ram6*s SCI)edule, mny bD ati&chnd (f mars apace Is raciLgmd) _.._..�..�,.,_..
D ices Exclusion Applies - Curtis Basey, Nicole Basey, Steve Mahan
Dk
0I)0001)0 L
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
City of El Segundo
Park & Racmational N ' AelrHamzea Rai S glTA"Tt'E
Alan: City Clerk
350 Main St Room 5
IEI Seaundo. CA 50245
Q 1988-2 014 ACORD CORPORATION. All rights reserved.
ACORD 26 (2014101) The .ACORD name and logo are registered reams of ACORD
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 0313
(Ed. 04-84)
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT
We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce
our right against the person or organization named in the Schedule. (This agreement applies only to the extent that
you perform work under a written contract that requires you to obtain this agreement from us.)
This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule.
Schedule
State Person or Organization Job Description
California City Of El Segundo All Operations
Park & Recreational
i Attn: City Clerk
350 Main St Room 5
El Segundo, Ca 90245
The additional premium charge for this endorsement shall be $25 per job for those listed above.
This endorsement changes the policy to which it is attached and is effective on the date Issued unless otherwise stated.
Republic Indemnity Company of America
Company Number 19739
Insured Inland Empire Stages Ltd
Pnli Number 156690-14
-E ;' d"ors -e m`e-nt-N`um—b-er 4
Endorsement Effective October 01, 2015
Printed On September 30, 2015
Countersigned by:
WC 00 0313 Insured Copy
(Ed, 04-84)
-A-1 --- I