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PROOF OF INSURANCE (2017) CLOSEDIt Is ceirtilled thal, It nanted below, this policy includes as AddillooW Insureds 1) the sponsor(s), prorytoter(s), orpnizor(s) (includ'108 other craid" having similar lntmcsts), of Insured pyrotechnic OVOMIS araVor 2) the owncr(K) afteal property (or barges) at which insured ppolochate oyents are hold and/or 3), the owner(a), mAneser(s), tenam(s), mortgoote(s) (Including other entitles baying similar Interests), of buildings, stadiums, menu and similar facilities at which insured pyrotechnic events are hold mid/or 4) the licensing or porinkting antholity, or other authority having joriodiction, Issuing licenso0pormits for Injured pyrolachal c events tuidlor 5) tiny other emity for which the Insurance Is, m4ulred to he afforded umler written contract. Covoregoapplics only as reapects the legal liability ofauch Additional lnqurod(s) for bodily laJury and property dam000 tiusod by the opmdons of the Named Insured, IU Insurance affattled any Additional Insured does not include coverage for any bodily injury or property damage arising from the falluro of such Additional insured to N11111 [is Oblisadolas specified in Its oontrut, with the Named, Invurad, 1 0 b I ' 0 1 1 11 4 141014 4 911"M (0) j0z City of R1 Soot'" 0 350 Main StJ245 El Segundo, CA 11))JOV maml I � Liz DISPLAY DA (S) July 4, 2016 It Is catlifled that this policy requires a 30 day mutual notice ofeancelladon between lite Insurer and the Namod Insured. tattle ovealofaudi Cancellation we will endeavor to mall to days written notice to the Additional Insitrod(s), whose name and orldram Is shown hereon, but raltum, to mall such notice shall Impose no obligation or liability of any Idad upon the Insuror andlor the undersigned, DATE OF ISSUE A. 1W *S t I N 0 WRO, 1 1-1 ii �81 1— DATE (MMIDWrfYY) CERT"IFICAT"E OF LIABILITY INSURANCE 411412016 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 certifioete holder Is an ADDITIONAL INSURED, the pollcy(Ies) must tie endorsed, If SUBROGATION IS WAIVED, Subject to the terms and conditions of the policy, certain policlas may require an endorsement. A statement on this certificate don not confer rights to the certificate holder in lieu of such endorsements , PRODUCER NNNBrr,. rlttorl Cleveland Gallagher En1i �1S «l t1.6 7100 u....,.. Itai° tS It 7101_ n11 nd C Center, Floor 30 1376 East 9th Street R '11:61. ... _...,, m .._ _.. 'aleveland OH 44114 INSURMU ) AFFOADt NO COVERAGE � NAM s' . INSURED INSUj!!tMwwiirn Iniiemndv Cemnan 6743 Pyro Spectaculars Inc. IIHSURSNC _ San Nip PreWorka P. O. pox 2329 INSUSNgB« - Rialto CA 92377' INSURER F: 1 COVERAGES CERTIFICATE NUMBER: 7995A1696 REVISION NUMBER: INDICATED, NOTWITHSTANDING ANY REOUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT NTH 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 yREpD�UCED�pBY PAID CLAIMS, Awk SUVA TYPE DP INSUPIA ICS VA P I Y N M rVM VYY �h FY�Y I LINTS MORAL LIABILITY EACH OCCURRENCE i °�� °riAs YO REWTYED COMMERC1ALOCNEr1ALUA6iLITY PfflyffaiF ,wu,� ) $ _. _ CLAIMSMADE OCCUR MAO E)(P la+v ores pereonl >ti L{dITAPPLMS PIER: AUTOMOaILi LIABILITY GENERALAOGREGATE i 5I6CA00031.161 1/1312018 111312017 t..., ANY AUTO $1000,000 BODILY INJURY (Per pawn) { BODILY INJURY (Per aWd@M i P OPIERpY)MAMAOE OWNED g i t AUTOS AUC TOBULED HIRED AUTOS AUTON S UMBRELLA LIAR X OCCUR EXC8017BS5 1113f2018 1/1312017 (. EXCESS LIAR CLAIM&MADE AND SMPLOYBRB LIABILITY ANY PROPRIRTORIPARINEMAECUTIVEa NIA gPPgpIM MOVA "C'LUDEDT RION OF OPKRATIONB 1 LOCATIONS 1 VBHICLEB (Attach ACORD 101, AddRlalal RamerNs Schedule, If more space Is required) Code: 52377 PERSONALS ADV INJURY { GENERALAOGREGATE i PRODUCTS - COMP /OP AGO S $1000,000 BODILY INJURY (Per pawn) { BODILY INJURY (Per aWd@M i P OPIERpY)MAMAOE i i EL EL 13 Policy Number: CA000002771 -30 CG 2010 07 04 Endorsement No. 118 Effective Date: April 14, 2016 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON O . ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Oreanization(s): Location(s) Of Covered Operations City of El Seg,ttltdo, its officers, officials, employees, All locations for which coverage is required by agents, and volunteers. written contract. 0 a Information reauired to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to This insurance does not apply to "bodily injury" or include as an additional insured the persons) or "property damage" occurring after: organization(s) shown in the Schedule, but only with 1. All work, including materials, parts or equipment respect to liability for "bodily injury", "property furnished in connection with such work, on the damage" or "personal and advertising injury" caused, project (other than service, maintenance or in whole or in part, by: repairs) to be performed by or on behalf of the 1. Your acts or omissions; or additional Insured(s) at the location of the 2. The acts or omissions of those acting on your covered operations has been completed; or behalf; 2. That portion of "your work" out of which the in the performance of your ongoing operations for the injury or damage arises has been put to its additional insured(s) at the location(s) designated intended use by any person or organization other above than another contractor or subcontractor engaged in performing operations for a principal as a part B. With respect to the insurance afforded to these W of the same project, additional insureds, the following additional exclusions apply, CG 2010 07 04 © ISO Properties, Inc., 2004 Page 1 of I I] Policy Number: CA000002771 -30 CG 20 37 07 04 Endorsement No. 119 Effective Date: April 14, 2016 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURE D - OWNERS, LESSEES OR CONTRACTORS - COMPLE"T"ED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Section 11— 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" or "property damage" caused, in whole or, in part, by "your work" at the location designated and , described in the schedule of this endorsement performed . for that additional insured and included in the "products... completed operations hazard ". CG 20 37 07 04 0 ISO Properties, Inc., 2004 Page 1 of 1 0 POLICYHOLDER COPY SD P.O. BOX 8192, PLEASANTON, CA 94588 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 04 -14 -2010 CITY OF EL SEGUNDO SD 380 MAIN ST EL SEGUNDO CA 90245 -3813 GROUP: POLICY NUMBER: OB03749 -2015 CERTIFICATE ID: 1343 CERTIFICATE EXPIRES: 10 -14 -2010 10 -14- 2016/10 -14 -2010 This is to certify that we have issued a valid Workers' Compensation insurance policy in a form apprdved by the California Insurance Commissioner to the employer named below for the policy period indicated, This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer, We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policy listed herein. Notwithstanding any requirement, harm or condltion of any contract or other document with respect to which this certificate of insurance may be issued or to which It may pertain, the insurance afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy. Aulhorixed Representative President and CEO EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT #2085 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 10 -14 -2002 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2018 -04 -14 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: CITY OF EL SEGUNDO EMPLOYER PYRO SPECTACULARS, INC. SO PO BOX 2329 RIALTO CA 92377 [P1 D,SDI tRIV.7.20141 PRINTED : 04 -14 -2016 ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION REP 25 803749 -15 RENEWAL SD 5- 41 -39 -14 PAGE 1 HOME OFFICE SAN FRANCISCO EFFECTIVE APRIL 14, 2016 AT 12.01 A.M. ALL EFFECTIVE DATES ARE AND EXPIRING OCTOBER 14, 2016 AT 12.01 A.M. AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME PYRO SPECTACULARS, INC. c ;[ PO BOX 2329 1� RIALTO, CA 92377 ANYTHING IN THIS POLICY TO THE CONTRARY NOTWITHSTANDING, IT IS AGREED THAT THE STATE COMPENSATION INSURANCE FUND WAIVES ANY RIGHT OF SUBROGATION AGAINST, CITY OF EL SEGUNDO WHICH MIGHT ARISE BY REASON OF ANY PAYMENT UNDER THIS POLICY IN CONNECTION WITH WORK PERFORMED BY, PYRO SPECTACULARS, INC. IT IS FURTHER AGREED THAT THE INSURED SHALL MAINTAIN PAYROLL RECORDS ACCURATELY SEGREGATING THE REMUNERATION OF EMPLOYEES WHILE ENGAGED IN WORK FOR THE ABOVE EMPLOYER. IT IS FURTHER AGREED THAT PREMIUM ON THE EARNINGS OF SUCH EMPLOYEES SHALL BE INCREASED BY 03 %. NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO. APRIL 18, 2016 AtI'I10 RII »D REI'IE'EIT' IVE PRESIDENT AND CEO SCIF FORM 10217 I'RW7.20141 2570 OLD DP 217