PROOF OF INSURANCE (2016) CLOSEDAC40RDr CERTIFICATE OF LIABILITY INSURANCE DATE(MMNDDIYYYYY)
SM==-- --] 0310412016
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(tes) must be endorsed. If SUBROGATION IS WAIVED;, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder In lieu of such endorsamlen 4 „
Sam My
an
PRODUCER Liberty United Insurance Services, Inc. PH -
6005 Vineland Avenue, Suite 203 51ia 8eu a2 a
North Hollywood, CA 91606 ELI SaI11 IlbaNt Ialllted)nsuraace.com
License #: OF89841 INSURERISI AFFORDING COVERAGE
_ NAIL
INSURERA: United States Fire Insurance Co
INSURED
INSURER B:
Elite Special Events, Inc INSURERC:
11278 Los Alamitos Boulevard #101 ERD:
INSUR
�u .._U. ..m...... ..... ...._. �
Los Alamitos, CA 90720 INSURERS
INSURER F:
COVERAGES CERTIFICATE NUMBER: 00000000 18884 REVISION NUMBER: 16
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.
TYPE OF INSURANCE ,ue un n POLICY NUMBER MA P LIMITS
A X COMMERCIAL GENERAL LIABILITY Y N SRPGP- 101 -0716 1012812015 10128/201 , EACH OCCURRENCE s 1.000.000
CLPJMS-MAOE ® OCCUR
: 300.000
4 MED EXP (AM one person) s 5.000
PERSONAL A ADV IWURY $ 1.000.000
AGRE APPUE `E GENERALAGGREGATE mm W ........ 000 000 � P C
PRODUCTS . COMPdOP ARQ s 2.000.000
TH'•R; S
AUTOMOBILELIABILm MII D s
ANY AUTO BODILY INJURY (Per person) S
AUTO03 ED AUTOSS BODILY INJURY (Par acddml) S
HIREDAUTO5 AUTOS�D S
.........
S
UMBRELLA LIAR OCCUR EACH OCCURRENCE S
EXCESS LIAR CLAIMS•MADE AGGREGATE $
D RETENTION .$ $
WORKGRS COMPENSATION
AND LIABILITY YIN ,� NT �,„„,.
ANY PROPRIET•OWPARTNERMMCU"Ntl'VE �........ NIA E.L. EACH ACCIDENT S
OFFICEFUMEMSER EXCLUDED? „n.� -. ..®._...... .- .. _... . _.
(Mandii;ry In NH) E L DISEASE. EA EMPLOYE S
IN ac ds
8 F �: 1 EL DISEASE. POLICY I1MR '..... S
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, AddlUwA Rem rks Schedule, may bs aNched If mors apace Is requlmd)
The City of El Segundo, Its officers, officials, employees, agents, and volunteers are named additional Insured
Scheduled Activities Exclusion Endorsement Applies: Mechanical Bulls, Mechanical Surfboards & Zip Lines
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
The C of El Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City 9 "w " ACCORDANCE WITH THE POLICY PROVISIONS.
350 Main Street
El Segundo, CA 90245 AUTHORIMO REPRESENT TII
r I ISMSI
1988.2014 ACORD CORPORATIOW All rights reserved.
ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
Printed by SMS on March 04, 2016 at 10:48AM
COMMERCIAL GENERAL LIABILITY
CG 20 26 07 04
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - DESIGNATED PERSON OR
ORGANIZATION
Policy Number. SRPGP- 101- 0715/USP195863
Insured: Elite Special Events, Inc
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person(s) Or
The City of El Segundo
350 Main Street
El Segundo, CA 90245
Section II - WHO IS AN INSURED is amended to
include as an 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 of the acts or omissions 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. wM
ons.
To the extent that any of the additional insureds
named herein are liable for occurrences arising out
of the named insured's negligent acts or omissions,
the insurance afforded to the additional insureds
under this endorsement is primary insurance over
any other valid or collectible insurance which the
additional Insureds may have with respect to loss
under any of the listed policies. Other insurance of
any additional insured applicable to loss is non-
contributory and excess over the coverage provided
by this endorsement, and the amount of the
company's liability under this policy shall not be
reduced by the existence of such other Insurance.
CO 20 26 07 04 0 ISO Properties, Inc., 2004 Page 1 of 1 G
COMMERCIAL GENERAL LIABILITY
CG 24 04 05 09
T *� F111M 10
This endorsement modifies insurance provided under the following:
Policy Number: SRPGP- 101- 0715/USP195863
Insured: Elite Special Events, Inc
COMMERCIAL GENERAL LIABILITY COVERAGE PART
PRODUCTS /COMPLETED OPERATIONS LIABILITY COVERAGE PART
Name Of Person Or Organization:
The City of El Segundo
350 Main Street
El Segundo, CA 90245
SCHEDULE
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.!;
CO 24 04 05 09 0 Insurance Services Office, Inc., 2008 Page 1 of 1 G
jai "K" CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY)
iih 3/9/2016
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 holster is an ADDITIONAL INSURED, the paollcy(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 on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER T. Dave Warren
Nielsen Mchnany Insurance Services, Inca PHONE (805) 379 -8801 IAIC 0 SM204 -4501
4165 E. Thousand Oaks Blvd r-
Suits 325 INSURERISI AFFORDING COVERAGE NAIC /
mmm_m
Westlake Village CA 91362 INSURERA:California Auto Insurance 38342
INSURED
INSURER B
INC. ELITE SPECIAL EVENTS INSURER C:
404 N Sparks St INSURER O:
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City Of El Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Attn: city clerk ACCORDANCE WITH THE POLICY PROVISIONS.
350 Main Street
El Segundo, CA 90245 AUTHORIZEDRIPMeSNTATIVE
®1988.2014 ACORD CORPORATION.. All rights reserved.
ACORD 28 (2014101) The ACORD name and logo are registered marks of ACORD
INS028 awol)
1/6/2016
Certificate of Exemption from Workers Compensation Insurance
To: City of El Segundo
From: Elite Special Events �
Subject: Sole proprietor, partnerships, closely held corporations with no employees
Please let these memorandums notify the City of El Segundo that I am a Closely held
Corporation and do not have any employees whose employment requires me to carry worker's
compensation insurance. Therefore, I do not carry worker's compensation insurance coverage.
Ted Holcomb
President
562 - 799 -7737