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PROOF OF INSURANCE (2016) CLOSED, DATE(MWDDYYY) ��? CERTIFICATE O LIABILITY INSURANCE ACE 04/19/2016 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 certilicato 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 polloles may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such andorsement(s). PRODUCER I P HCC Specialty 401 Edgewater Place, Suite 400 lwd5" Wakefield, MA 01880 INSUREWS AFFORDING COVERAGE NAIL R INSURED INSUReRA: New HemDShire Insurance Companv 23841 Mike D. Palombo/Tombstone Shadow Revival/ The Bedairs (Rock 8: INSuReRs: United States Fire Insurance Comnanv 21113 Soul) Band INSURERC: 2258 Pepperwood Ave INSURER D; Long Beach, CA 90815 INSURERE: INSURER F - L—= COVERAGES CERTIFICATE NUMBER: REVISION NUMBER. THAN IS TO CE8TIFY THAT THE POLICIES OF INSURANCE LISTED BELOW 14AVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REOUIREMENT TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAN, �HE 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. Am INSA TYPEOFINSURANCE ells uvve POLICYNUMBPR /M..___ M MMIL LIMITS OENERALLIABILITY ao z 1 o 04/28/2016 07/07/2016 EACH OCCURRENCE •� TI'S RENTED" $ 1,000,000 CCdMMERCIAL 13MrNERAL LIABILITY PpIEMIREB IEa em,rt. $ 0 OCCUR CLAIMS -MADE use EYP IAm, a 5.000 ..®..gym., - X Host Liquor PERSONAL aADVINJURY S 1,000,000 B X Medical Ex pense US573775 04/28!2018 07/07/2018 aENERALA� REaaTE c 2,000,000 GENL AGGREGATE LIMIT APPLIES PERt PRODUCTS - COMP/OP AGO : 11000,000 X � POLICY PP 1 LOC : AUTOMOBILE LIABILITY 6509RE15 1143M [iorT : (Es AtNAldant) ANY AUTO BODILY INJURY (Par Panora) S� ALL OWNED AUTOS BODILY INJURY (Per accident) S SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS (Par aoddenl) NON -OWNED AUTOS i S_ UMBRELLA LIAR OCCUR EACH OCCURRENCE S EXCESS LIAO CLAIMS-_ E AGGREGATE i DEDUCTIBLE t RErENTION It S WORKER$ COMPENSATION AND EMPLOYERS "LIABILITY YIN I� ANY PROPRIErOWPARTNERIEXECUTIVE E.L. EACH ACCIDENT I E OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E-L- DISEASE. EA EMPLOYE„ S II yyeaaa describe under f)Ef:fSFll¢TIAN OF QPI- NATIf1NR 6,J,e,n, E.L DISEASE- POLICY LIMIT DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (Attach ACORD 101, Addllionai RemarkeSchedule, If mono apace N lequirod) The Certiacera Holder Is added as Additional Insured YAM respects to our Insureds operations only. This Inaranoe Is prbnary and mnconWbulory as raguIred by vniden cent a t. Uat of events covered under On above pallor numbers oan be vlawed on pope 42 of the ontiltaate of Insurance form CER'TIF'ICATE HOLDER CANCELLATION City of El Segundo, its officers, Officials, employees, agents, and SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DA"L"E THEREOF, NOTICE WILL BE DELIVERED volunteers IN ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main St El Segundo, CA 90245 AUTHORIZEDREPRESENTAT II� ACORD 25 (2010105) ®1988.2010 ACORD CORPORATION, All rights reserved. Page 2 of Certificate of Liability Insurance Policy Numbers: SEL064081210 US573775 Date: 04/19/2016 1) This coverage Is with respect to Summer Concert Series event to behold 6/19/2016 - 6/19/201612:00:00 AM at Recreation Park El Si 2) This coverage is with respect to Summer Concert Series- 4th July Concert event to be held 714/2016 - 7/4/201812:00:00 AM at Recre THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ENDORSEMENT This endorsement, effective 12:01 A.M. Apr 28, 2016 To Jul 07, 2016 12:01 A.M. Fors apart of Policy No.: 64081210 Issued to: Mike D. Palombo/Tombstone Shadow Revival/ The Berlairs (Rock & Soul) Band By: New Hampshire Insurance Company ECONOMIC SANCTIONS ENDORSEMENT This endorsement modifies insurance provided under the following, The Insurer shall not be deemed to provide cover and the Insurer shall not be liable to pay any claim or provide any benefit hereunder to the extent that the provision of such cover, payment of such claim or provision of such benefit would expose the Insurer, its parent company or its ultimate controlling entity to any sanction, prohibition or restriction under United Nations resolutions or the trade or economic sanctions, laws or regulations of the European Union or the United States of America. AUTHORIZED REPRESENTATIVE 896446-13 POLICY NUMBER: 64081210 COMMERCIAL GENERAL LIABILITY CG 20 110413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Designation Of Premises (Part Leased To You): City of El Segundo, its officers, officials, employees, agents, and volunteers, 350 Main St, El Segundo, CA, 9024 Name Of Person(s) Or Organization(s) (Additional Insured): City of El Segundo, Its officers, officials, employees, agents, and volunteers, 350 Main St, El Segundo, CA, 9024 Additional Premium: Included 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 2. If coverage provided to the additional insured include as an additional insured the person(s) or Is required by a contract or agreement, the organization(s) shown in the Schedule, but only insurance afforded to such additional insured with respect to liability arising out of the will not be broader than that which you are ownership, maintenance or use of that part of the required by the contract or agreement to premises leased to you and shown in the provide for such additional insured. Schedule and subject to the following additional B. With respect to the insurance afforded to these exclusions: additional Insureds, the following is added to This insurance does not apply to: Section III — Limits Of Insurance: 1. Any 'occurrence" which takes place after you If coverage provided to the additional Insured is cease to be a tenant in that premises, required by a contract or agreement, the most we 2. Structural alterations, new construction or will pay on behalf of the additional insured is the demolition operations performed by or on amount of insurance: behalf of the person(s) or organizations) 1. Required by the contract or agreement; or shown in the Schedule. 2. Available under the applicable Limits of However: Insurance shown in the Declarations; 1. The Insurance afforded to such additional whichever is less, insured only applies to the extent permitted This endorsement shall not increase the by law; and applicable Limits of Insurance shown in the Declarations. CO 20 110413 0 Insurance Services Office, Inc., 2012 Page 1 of 1 POLICY NUMBER: 64081210 COMMERCIAL GENERAL LIABILITY CG 20 26 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. 0 0 This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE 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 Is% and 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. 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, CG 20 26 0413 ® Insurance Services Office, Inc„ 2012 Page 1 of 1 M104 ENDORSEMENT # 1 THIS ENDORSEMENT EFFECTIVE: 12:01 A.M., 5/16/2016 FORMS APART OF POLICY NO. 64081210 BY: NEW HAMPSHIRE INSURANCE COMPANY hsaed To: Alike D. Palumbo/Tombstone Sbadow Revival/ The Berlaks (Rock 8i Soul) Band The SportsUisure/Entertaiameat Activities and Devices Exclusion Endorsement 100456 (3109) is amended to delete the following exclusion: "pet{ormers° All other terms and conditions remain the same. AUTHORIZED SIGNATURE ENDORSEMENT THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement, effective at 12:01 A.M. Apr 28, 2016 forms apart of Policy No. 64081210 Issued to: Mike D. Palombo/Tombstone Shadow Revival/ The Beriairs (Rock & Soul) Band By: New Hampshire Insurance Company EXCLUSION -- SPORTS /LEISURE /ENTERTAINMENT ACTIVITIES AND DEVICES This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM The following exclusions are added to Paragraph 2. Exclusions of COVERAGE A BODILY INJURY AND PROPERTY DAMAGE LIABILITY (SECTION I — COVERAGES) and Paragraph 2. Exclusions of COVERAGE B PERSONAL AND ADVERTISING INJURY LIABILITY (SECTION I — COVERAGES) if an X is indicated to the left of such exclusion.:. This insurance does not apply to "bodily injury", "property damage ", "personal and advertising injury" Inverted Aerial Maneuver Arising out of the attempt to perform or performanc a of any inverted aerial maneuver by a skier from a jump: 1. Built by you or on your behalf, or 2. Built on your premises with your permission or knowledge. X Amusement Device Arising out of the ownership, operation, maintenance or use of any "amusement device ". For purposes of this exclusion, "amusement dev ice" means any device or equipment a person rides for enjoyment, including, but not limited to, any mec hanical or non - mechanical ride, slide, water slide (including any ski or tow when used in connection with a water slide), moonwalk or moon bounce, bungee operation or equipment. "Amusement device" does not include any video arcade or computer game. Bungee Arising out of the ownership, operation, main tenance or use of any bungee operation or equipment whether owned, operated, maintained or used by you, any other insured or any other person or entity. Animals Arising out of injury or death to any anlmal. Object Propelled Arising out of any object propelled, whether intentionally or unintentionally, into the crowd by or at the direction of a "participant" or Insured. X "Participant" Arising out of the involvement of a participant in any activity, event or exhibition, including, but not limited to, any contest, physical training, sport, event, athletic activity, martial arts or stunt. Rodeo Arising out of any rodeo activity, including, but not limited to, bronco or bull riding, steer roping, team roping, barrel racing or horseback riding. 100456 3 09 Page 1 of 2 Concert Arising out of a concert, show, or theatrical event. X Performer Arising out of the involvement of any performer duri ng any activity, event or exhibition, including, but not limited to any stunt, concert, show or theatrical event. DEFINITION OF PARTICIPANT For purposes of this endorsement, "participant" means any person while instructing, supervising, training or practicing for, participating in or while otherwise involved in any sports or athletic activi ty, contest, or exhibition. "Participant" does not include any spectator. All other terms, conditions and exclusions remain unchanged. Authorized Representative 100456309 Page 2 of 2 FOLD TOPAND BOTTOM OF CARD ON PERFORATIO erarm CALIFORNIA ��. INSURANCE CARD NIDENTIFICATION CAL, S MUTL VOL STATE FARM® FOLD TOPAND BOTTOM OF CARD ON PERFORATION Stag Farm Mutual Automobile Insurance Company 900 Old River Road Bakersfield CA 93311-9501 INSURED PALOMBO, MIKE MUTL VOL stateFarm CALIFORNIA INSURANCE CARD���� State Farm Miutual Automobile Insurance Company 900 Old River Road Sakerstleld CA 93311 -9501 INSURED PALOMBO, MIKE MUTL VOL POLICY NUMBERC949940- E20 -75F EFFECTIVE POLICY NUMBER C949940- E20 -75F EFFECTIVE YR 2006 MAKE FORD MAY 20 2016 TO NOV 20 2016 YR 2006 MADE FORD MAY 20 2016 TO NOV 20 2016 MODEL RA MA VIN 1FTYR14UR6PA31445 MOIIEL RANGER VIN 1FTYR14UXOPA31448 AGENT RA OY SCIIAUER 6601 -A2D A11 NT RANDY SC IAUER 8801 -A20 PHONE V � THE Rt POLICYIMEE S1THE MINIMUM LIABILITY LlMrf THE PO IG"Y EAS 7 I MINIMUM LIABILITY LIMBS 1IEREVIRSESIOEMRAN EVLMAY1044 a91E*RffSIDkrDRM TItM, KEEP A CARD IN YOUR CAR. SUBMIT THIS CARD, OR A PHOTOCOPY OF THIS CARD, WITH YOUR VEHICLE REGISTRATION RENEWAL. 15797116797 KEEP YOUR CURRENT CARD UNTIL THE EFFECTIVE DATE OF THIS CARD. s4- FENDS tiff5707 UUte.105- M-20121o1pccelbl CITY OF EL SEGUNDO WORKERS' COMPENSATION DECLARATION WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SUBJECTS AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN LABOR CODE § 3706, INTEREST, AND ATTORNEY'S FEES. I affirm under penalty of perjury under the laws of California one of the following declarations: (_) I have and will maintain a certificate of consent of self - insure for workers' compensation, issued by the Director of Industrial Relations as provided for by Labor Code § 3700 for the performance of the work set forth the agreement with the City of El Segundo. Policy No. (___) I have and will maintain workers' compensation insurance as required by Labor Code § 3700 for the performance of the work for which the agreement with the City of El Segundo is executed. My workers' compensation insurance carrier and policy number are: Carrier Policy Number Expiration Date Name of Agent Phone # ertify that, in the performance of the work set forth in the agreement with the City of EI Segundo, I will not n any person in any manner so as to become subject to the workers' compensation laws of California, and agree that, if I should become subject to the workers' compensation provisions of Labor Code § 3700 1 must immediately comply with those pr visions or the reement will automatically become void. Signature of Applicar Date OJ` D1— %,� 0 Agreement for: �a- Dated: Reviewed by: