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PROOF OF INSURANCE (2016) CLOSEDA1. C> a.../ CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) 03/07/2016 PRODUCER THIS cMURUATOW is 199905 A9 A ED TTE OF INFORMATr0-ff- East Main Street Insurance Services, Inc, ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Will Maddux HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR PO Box 1298 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Grass Valley, CA 95945 Phone: (530) 477 -6521 Email: Info@theeventhelper.com INSURERS AFFORDING COVERAGE NAIC # INSURED .... ..- .__... .......... ___� INSURERA: Essex Insurance Company 1 39020 The Polynesian Dance Company INSURER B: Jordan Orlick 8383 Wilshire Blvd #800 INSURER C: Beverly Hills, CA 90211 INSURER D: INSURER E: COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INS LTR ADD' IN SR TYPE OF INSURANCE POLICY NUMBER POLICY E;ffSCTIVS CATS MmmorYY POLICY EXPIPoATIDN DATE MMrD01YY LIMBS GENERALLIAaILITY EACH OCCURRENCEe+awM 9 1,000,000 00CM Y KAMY& FKW1a,ry n� K A Y COMMERCIAL GENERAL LIABILITY 3DS5450- M930974 08/11/2016 08/12/2016 MED EXP (Any one person) s 6.000 CLAIMS MADE © OCCUR PE',RSONAL,& ADV INJURY S 1,000 000 ' Host Liquor Liability 3DS5450- M930974 08/11/2016 08/12/2016 GENERALAGGREGATEw 5 2,000,000 OEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOPAGO $ 1,000,000 >91 POLICY JECT LOC DEDUCTIBLE $ 1,000 L Retail I I uOr Llablflt _...._ _ ... ............_ 5 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S ANY AUTO (Ea seddent) ALL OWNED AUTOS BODILY INJURY S SCHEDULED AUTOS (Per person) HIRED AUTOS ' BODILY INJURY S NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE S (Per awident) OARAGE LIABILITY AUTO ONLY - PA ACCIDENT S ANY AUTO OTHER THAN EA ACC S I AUTO ONLY: AGO S EXCEBS'IUMBRELLA LIABILITY EACH OCCURRENCE S OCCUR FI CLAIMS MADE AGGREGATE S a DEDUCTIBLE S RETENTION $ S WORKERS COMPENSATION AND TORY LIMITS EA EMPLOYERS` LIABIUTY' E.L EACH ACCIDENT S .�, ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYE 6 if describe under — SPECIAL MORE below E.L. DISEASE - POLICY LIMIT 1 S OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Certificate holder listed below Is named as additional Insured per attached CG 20 28 07 04. Primary/Non-Contributory wording applies per attached MEGL 0010 0311. Waiver of Subrogation applies per attached CG 24 04 05 09. E City of El Segundo, SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BO CANCELLED BEFORE THE EXPIRATION Its Officers, Offlotals, ern(11Oyeos, DATE THEREOF, THE ISSUING INSURER WILL 640#AMOA40MAIL 30 DAYS WRMW agents, and Volunteers C` 350 gain St,, NOTICE TO THE CERTIFICATE 14OLDER NAMED TO THE LEFT, 151 Segundo, CA 90245 I ti, AUTHORIZED REPRESENTATIVE 7 1 /d Policy Number: 3DS5450- M930974 COMMERCIAL GENERAL LIABILITY CG 20 26 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OIL 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 orgeni- zation(s) shown In the Schedule, but only with respect to liabillty 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. CO 20 26 07 04 0 ISO Properties, Inc., 2004 Pape 1 of 1 0 COMMERCIAL GENERAL LIABILITY POLICY NUMBER: 3DS5450- M930974 Essex Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED ENDORSEMENT - PRIMARY AND NON - CONTRIBUTORY This endorsement modifies Insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM PRODUCTS /COMPLETED OPERATIONS LIABILITY COVERAGE FORM SCHEDULE City of El Segundo, Its officers, officials, employees, agents, and volunteers 350 Main St. El Segundo, CA 90245 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 II — 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. Policy Number: 3DS5450- M930974 COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 OP I lk This endorsement modifies Insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTSICOMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Person Or Organization: City of El Segundo, Its officers, officials, employees, agents, and volunteers 350 Main St. El Segundo, CA 90245 Information reaulred to complete this Schedule. if not shown above, will be shown In the Declarations. The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV — Conditions: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for Injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products - completed operations hazard ". This waiver applies only to the person or organization shown in the Schedule above. CG 24 04 05 09 0 Insurance Services Office, Inc., 2008 INSURANCE COMPANY AGENCYICOMPANY ISSUING CARD Esurance Property and Casualty Esurance Insurance Services, lna Insurance Company P. O. Box 5250 650 Davis Street Sioux Fells, SO 571175250 San Francisco, CA 94111 NAIL # 30210 POLICY NUMBER EFFECTIVE DATE EXPIRATION DATE PA 0362 December 04, 2015 June 04, 2016 YEAR MAKE)MODEL 2010 Chevrolet -CAMARO LS INSURED NAME AND ADDRESS JORDAN ORLICK 11443 AWENITA COURT CHATSWORTH, CA 91311 VEHICLE IDENTIFICATION NUMBER 2G1FA1EVBA9111413 ADDITIONAL LISTED DRIVER(S) Esurance policyholders can renew their vehicle registration online with the CA DMVI See your next DMV renewal notice or visit www.dmv.cs.gov for more Information. The policy meets We requirements of Section 16056 of the California Vehicle Code. ORIGINAL VEHICLE AND PRESENTED UPON DEMAND Our Contact Information Customer service and claims center. 15D0- ESURANCE (1500376 -7262) Email: supporecsir.asuranos.com Web site: www.asurance.com If you get into an accident Seek medical assistance if necessary. Report the accident to the police. Do not discuss the accident with anyone except the police. Do not admit fault. Contact an Esurance Claims representative as soon as possible to report the accident 1500 - ESURANCE (14W-378-7262). Write dawn the names, addresses, license numbers, vehicle descriptions, number of passengers, and Insurance information of everyone Involved In the accident. Write dam the names, addresses, and phone numbers of witnesses. Take photos of the accident area and vehicle damage if you happen to have e camera with you. Do not sign any documents except those provided by Esurance or law enforcement authorities.