PROOF OF INSURANCE (2016) CLOSEDCity of El Segundo, Its officers, officials, employees, agents, and
volunteers
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ACORD 36 (3010106) 01086.2010 ACORD CORPORATION. All Nghte reserved.
POLICY NUMBER: 64081412
COMMERCIAL GENERAL LIABILITY
CG 20 26 0413
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
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
law; 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 0 Insurance Services Office, Inc., 2012
Page 1 of 1
POLICY NUMBER: 84081412
COMMERCIAL GENERAL LIABILITY
CO 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):
Library Park, 800 Main St, El Segundo, CA, 90245
Name Of Person(s) Or Organlzatlon(s) (Additional Insured):
Library Park, 800 Main St, El Segundo, CA, 90245
Additional Premium: Included
Information required to com late this Schedule If not shown above will be shown In the Declarations.
A. Section II — Who Is An Insured Is emended to
2. If coverage provided to the additional Insured
Include as an additional Insured the person(&) or,
Is required by a contract or agreement, the
organlatlon(s) shown in the Schedule, but only
Insurance afforded to such additional Insured
with respect to liability arlsin out of the
ownership, maintenance or use of that the
will not be broader than that which you are
part of
required by the contract or agreement to
promises, leased to you and shown in the
provide for such additional Insured,
Schedule and subject to the following additional B.
exclusions:
With respect to the Insurance afforded to these
additional Insureds, the following Is added to
This insurance does not apply to:
Section I'll — Limits Of Insurance:
1. Any "occurrence" which takes place after you
If coverage provided to the additional Insured Is
cases to be a tenant. In that promises.
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 parson(s) or, organization(s)
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 lass.
Insured only applies to the extent permitted
by law; and
This endorsement shall not increase the
applicable Limits of Insurance shown In the
Declarations.
CO 20 110413 0 Insurance Services Office, Inc., 2012 Page 1 of 1
POLICY NUMBER: 64081412
COMMERCIAL GENERAL LIABILITY
CG 2012 07 98
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL
STATE OR POLITICAL SUBDIVISIONS - PERMITS
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
State Or Political Subdivision:
As submitted to company and required by written contract.
(If no entry appears above, Information required to complete this endorsement will be shown In the Declarations as
applicable to this endorsement.)
Section II — Who Is An Insured Is amended to 2. This insurance does not apply to:
Include as an insured any state or political subdivi.. a. " "Bodily injury,'" "property damage "" or " "personal
sion shown In the Schedule" subject to the following and advertising injury"' arising out of opera -
provisions: tions performed for the state or municlpality,
1. This insurance applies only with respect to opera- or
tions performed by you or on your behalf for b. "BodUy injury"' or ' "property damage" included
which the state or political subdivision has Issued' within the "products - complated operations
a permit.
hazard ".
CG 2012 07 98 Copyright, Insurance Services Office, Inc., 1997 Page 1 of 1 13
ENDORSEMENT
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
This endorsement, effective at 12:01 A.M. May 04, 2016 forms a part of Policy No. 64081412
Issued to: Dax Kimbrough/ Centerfold Hits of the 80's
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 tenence 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 animal.
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.
100456309 Page 1 of 2
Concert
Arising out of a concert, show, or theatrical event.
X Performer
Arising out of the involvement of any performer dud 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
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:
U 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.
U 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
Name of Agent
Policy Number Expiration Date
Phone #
Lx_) I certify that, in the performance of the work set forth in the agreement with the City of El Segundo, I 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 l',
must immediately comply with those provislonsl °orthe agreement will automatically become void,
Signature ofApplicant _ Date 4,1316
Agreement for: IF
Dated: (0 -,-e)- I U
Reviewed by: 1�we)
..;