PROOF OF INSURANCE (2017) CLOSEDZEBRA-1 OP ID: JJ
I DATE (MWDDfYM)
CERTIFICATE OF LIABILITY INSURANCE 02111/2016
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 certificate holder Is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement an this certificate does not confer rights to the
certificate holder In lieu of such endorsement(s).
PRODUCER 10 , Am , Dick Wardlow Ins Brokers
Dic. ick Ward! 00 IAM-
Insurance Brokers PH 19.11- 805-5 53-0506
L #OB99800 N.-
233 High Street 1W,
Moovark CA 03021 ADORE,&
Dick arJlowlnsBrokers INSURERISIAFFORDING COVERAGE NAIC 0
INSURED r-eura r-rixerLainment ano r-venxs INSURERS
Shelly Mazer
11024 Balboa Blvd #118 INSURER C;
Granada Hills, CA 913"
1115441VOW-w- -4 :. - ;; AN
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.
NSR
T
TYPE OF INSURANCE
INSR
WON
kl.--
oni try MUMMER
ANOLMRML
ICY txp
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE
S 1'000.006
COMMERCIAL GENERAL LIABILITY
x
3DS5451-M908894
0=612016
021`0612017
F ORLNTED
ICE
$ 100,00
�1 CLAIMS -MADE F1 OCCUR
MED EXP (Anw one pown)
S 5,00q
PERSONAL& AOV INJURY
S 1,000.00
GENERALAGGREGATE
S 2,000,000
GEN't AWRIGATE LIMIT APPLIES PER:
PRODUCTS-COMPIOPAGG
S 11000,000
71 POLICY E M 0 LOG
Deduct
8 1.000
AUTOMOBILE LL481UTY
COM SINED SIRaEnW
IRA 909,199
ANY AUTO
BODILY INJURY (Per persm)
8
ALL OWNED
AUTOS
SCHEDULED
AUTOS
BODILY INJURY (Per socklent)
3
HIRED AUTOS
NON
AUTOS -OWNED
I WPE MRA FC �YQ SMM F1
S
UMBRELLA LIAR
OCCUR
EACH OCCURRENCE
5
EXCESS LIAR
1�
CLAIMS -MADE
AGGREGATE
$
WORKERS COMPENSATION
ER IOTH-
1AS'111T141 I R
AND EMPLOYERS* LIABILITY YIN
ANY PROPMETORMARTNER"ECUTWE ❑
dftJ,6EJWkMR6,,4 EXCLUDED?
NJA
E.L. EACH ACCIDENT
5
(Mandatory In NH)
E.L. DISEASE - EA EMPLOYEE
S
do vAbo und
0 n4IPT ION Of Ow PERAT12NS b0tw
DISEASE- POLICY LIMIT
$
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Ackfillonal Remarks Scheftle, Ir mom space Is requIred)
The City of El Segundo, its officers, officials, euployeas, agents and
volunteers are named as Addll insureds, but only insofar as the operations
under this Written Contract are concerned. This Policy is Primary a Non-
Contributory.
All Event Dates.
^A 11^Y I, I A" 1^kA
CO-ESOO
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,
City of El Segundo ACCORDANCE WITH THE POLICY PROVISIONSNOTICE WILL BE DELIVERED IN
350 Main Street
El Segundo, CA 90246 AUTHORIZED REPRESENTATIVE
GSA "'
01968 -2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010106) The ACORD name and logo are registered marks of ACORD
Policy Number: 3DS5450- M908894 COMMERCIAL GENERAL LIABILITY
CG 20 26 07 04
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - DESIGNATED
PERSON OR ORGANIZATION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Section II — Who Is An Insured is amended to in-
clude as an additional Insured the person(s) or organi-
zation(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 omis-
sions of those acting on your behalf;
A. In the performance of your ongoing operations; or
B. In connection with your premises owned by or
rented to you.
CG 20 26 07 04 0 ISO Properties, Inc., 2004 Page 1 of 1 a
COMMERCIAL GENERAL LIABILITY
POLICY NUMBER: 3DS5450- M9O8894
Essex Insurance Company
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED ENDORSEMENT -
PRIMARY AND NONCONTRIBUTORY
This endorsement modes insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE FORM
PRODUCTS /COMPLETED OPERATIONS LIABILITY COVERAGE FORM
SCHEDULE
ADDITIONAL INSURED
P'E'RSON OR ENTITY:
City of El Segundo
Its Officers, Officials, Employees,
Agents and Volunteers
350 Main Street
El Segundo, CA 80245
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.
SECTION 11— WHO IS AN INSURED is amended to include as an Additional Insured the person(s) or entity(s) shown
in the Schedule above, but only as respects negligent acts or omissions of the Named Insured and only for
"occurrences ", "claims" or coverage not otherwise excluded by this insurance.
Where no coverage applies to the Named Insured, no coverage or defense applies to the Additional Insured shown in
the Schedule above.
No coverage applies to the Additional Insured scheduled above for any "bodily Injury ", "personal and advertising,
injury ", or "property damage "" 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.
Subject to the above, when coverage applies to the Additional Insured(s) listed) above, it shall be primary insurance as
respects any "claim", loss, or liability arising out of the Named Insured "s operations as covered by this Insurance. If
coverage applies under this policy„ any other Insurance maintained by the Additional Insured(s) as a Named Insured
shall be excess and' non - contributory to the coverage provided by this Insurance.
All other terms and conditions remain unchanged.
MEGL 0010 0311 Includes copyrighted material of Insurance Services Office, Inc.
with Its permission.
City of El Segundo-Recreation and Parks
Monse Palacios
401 Sheldon Street
El Segundo, CA 90245
Regarding: All Event Dates - 2016
Dear Ms. Palacios,
This confirms that Zebra Entertainment and Events does not own or rent any vehicles, and
therefore does not carry any Automobile Liability Insurance. We cannot cover vehicles privately
owned by Independent Contractors. Our Insurance carrier does not offer coverage for hired
and non owned vehicles for our class of business.
The operators we contract with are all Independent Contractors, and not employees, so
therefore we are not required to carry any Worker's Compensation policy for them, according to
the California Labor Code.
Thank You,
Shelly Mazer, owner
Zebra Entertainment and Events
11024 BalboaBhd Suft 118 GranadaM11A CalVornla 91344 818. 368.1818 wmxZabrolWerra7nnunMRd5venrs,con
May 261611:17a Zebra Entertainment & Ev 8183047558 p.4
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 taws 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:
Cartier Policy Number Expiration Date
Name of Agent Phone *
(ff I certify that, in the performance of the work set forth its the agreement with the City of El Segundo,] will not
employ 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 prcvjj1qps or thqagregpent will automatically become void.
Signature of Applicant
Agreement for.
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Dated: ot, • o� - t to
Reviewed b- i t
Date ✓f"XC —AP