PROOF OF INSURANCE (2016) CLOSED' ' CERTIFICATE OF LIABILITY INSURANCE DATE 05/17/217/2IY016
�. 6
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 endomement(s).
Western Sentry Insurance Brokers
4212 E Los Angeles Ave #9
Simi Valley CA 93063
INSURED
.terry Glenn
805 -577 -8522
INSURERA.- TheAmerican Insurance Co / FFIC
888 -875 -2902
Bell Event Services Inc
INSURER C:
531 Main St #228
INSURER D:
El Segundo CA 90245
INSURERE:
INSURER F:
COVERAGES CERTIFICATE NUMBER:
REVISION NUMBER;
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.
TO
TYPE OF INSURANCE
Vlk I
WN
POLICY NUMBER
19MM
COVES
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE
6
1,000,000
COMMERGAL GENERAL UABILnY
MI§ .. �
$
100,000
1CSIMS- MN4l5E ®OCCUR
MED EXP /Any one Person
$
10,000
A
x
BHSABC80900222
10/25116
10/25/16
PERSONAL a ADV INJURY
��
$
--
11000,000
GENERALAGGREGATE
$
2,000,0
GEI"Nt AGGREGATE LINITAPPUESPER:
PRODUCTS - COMP /OPAGG
S
2,000,000
POLICY EPROt LOG
AUTOMOBILE LIABILRY
COMBINED SINGLE LIMIT
i
ANY AUTO
(Ea accident)
ALLOWNEDAUTOS
BODILY INJURY r
N:P Defson)
_S .....
SCHEDULEDAUTOS
BODILY INJURY rpersm)l
6
PROPERTY DAMAGE
HIRED AUTOS
(Peraoddenl)
S
NON- OWNEDAUrOS
S
S
UMBRELLA LUIS
OCCUR
EACH OCCURRENCE
S
�
EXCESS LIAR
CLAIMS -MADE
AGGREGATE......
S
DEDUCTIBLE
6
RETENTION 6
S
%%f
N AND
IT
E
$V YIN
ER
ANY PROPRXETOTPARTN ERrE XECJTIVE �
EL EACH ACCIDENT
S
FICERFlMEMBER OE
N I A
(Mandatory In NH)
EL DISEASE -EA EMPLOYEE
S
If yyaa� describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT S
DESCRIPTION 11 OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional RemaAn Schedule, If more space to required)
Additional Insured: City of O Segundo, Its officers, officials, employees, agents and volunteers As perA8918941.07
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
City of EI Segundo EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH
350 Main St Rm 5 THE POLICY PROVISIONS.
El Segundo CA 90245 -3613
AUTIIOR¢SO REPRSSSNTATIVE
Certified Signature—- --- -Jerry Glenn
01988.2009 ACORD CORPORATION. All rights reserved.
ACORD 26 (2009109) The ACORD name and logo are registered marks of ACORD
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ABC MultiCover - AB 9189 08 07
This endorsement modifies insurance provided under the following:
American Business Coverage
Your policy is broadened and clarified as follows:
Blanket Additional Insured 1
Section II - Uabillty Coverage, Paft I. Who Is An
Insured, Item 2. is amended to include:
Any person or organization-oat you am re-
quired by a written. Insured co tract to include
as an insured, subject to all f the following
provisions:
(1) Coverage is limited to thic"ur liability aris-
ing out of:
(e) a state or political subdivision per-
mit issued to you.
(2) Coverage does not apply to any occur-
rence or offense:
(a) which took place before the exe-
cution of, or subsequent to the
completion or expiration of, the
written insured contract, or
(b) which takes place after you cease to
be a tenant in that premises.
(a)
the Ownership, mairitenance or use
(3) With respect to architects, engineers, or
of that part of the premises, or land
surveyors, coverage does not apply to
owned by, rotted 1+ , or leased to
Bodily Injury, Property Damage, Per -
you; or
sonal Injury or Advertising Injury arising
(b)
your ongoing opera ` ohs performed
out of the rendering or the failure to
render any professional services by or for
for, that insured; or
:
you including:
(c)
that insured's fnan ' control of
(a) The preparing, approving, or failing
you; or
to prepare or approve maps, draw -
(d)
the maintenance, o .ralion or use
ings, opinions, reports, surveys,
by you of equipmen leased to you
change orders, designs or specilica-
by such person(s) or tion(s);
tions; and
or
W
(b) Supervisory, inspection, or engi-
neering services.
If an Additional Insured endorsement is attached
to this policy that specifically names a person or
organization as an insured, then this coverage does
not apply to that person or organization.
This Forth must be attached to Change Endorsement when issued nkr the policy is written.
One or the Fireman's Fund Inwronco Companies as named in the policy n `
LAL
Secretary U President
,C
AH9119 X07
"' ss Page 1 of 6
PROGRESSIVE
PO BOX 94739
CLEVELAND, OH 44101
Named insured
MICHAEL J BELL
BELL EVENT SERVICES
531 MAIN ST *228
EL SEGUNDO, CA 90245
'�A
Commercial Auto
Insurance Coverage Summary
This is your Declarations Page
Your coverage has changed
Policy number: 04315274-6
Undervirriften by:
Progressive Express Ins Company
December 31, 2015
Policy Period: Aug 21, 2015 - Aug 21, 2016
Page I of 2
progressive.com
online Service
Make payments, check billing activity, pnnt
policy documents, or check the status of a
claim.
1-800-895-2886
For customer service and claims service,
24 hours a day, 7 days a week.
Yourcoverage began on August 21, 2015 at 12:01 a,m. This policy expires on August 21, 2016 at 12:01 a.m.
This coverage summary replaces your prior one. Your insurance policy and any policy endorsements contain a full explanation of your
coverage. The policy limits shown for an auto may not be combined with the limits for the same coverage on another auto, unless the
policy contract allows the stacking of limits. The policy contract is form 6912 (06/10), The contract is modified by forms 1303CA
(04/08),11198(OVO4),4852CA (10/04),4881CA (12/04)andZ228(01/11).
The named insured organization type is a sole proprietorship.
Policy changes effective December 29, 2015
Pr'e'm rum change: 111&00
....... T. h--e ... ciii-v-e- -r- i n--fo--r- m-- a-ii'o- n- -h- a'sc hin" ge d-," � ...... ... ...
The changes shown above will not be effective prior to the time the changes were requested,
Outline of coverage
Description Limits
...... ........... ......... ...................................
Deductible Premium
.....
b�b i I' iWfo- bih'e-r'i .............. — .....................
'
$
e
J��i!y.!njury and Property Damage Liablity $750,000combin cls�n
..... . .................. -- .. ..... -- .... ....
........ ........
Unirlsure0n�e-nnsurecl Motorist 'Retwed
.11 — 1. .1. .1 ... ...... ............. .......... ........ ..
Uninsured Motorist Property Damage Rejected
Subtotal policy premium
. .........
$2,628.00
. ........... ....
61 i'loinia 'V-ehi"c'le ... A'sies'sm-e-n-t liee, ... * .............................. * ..........................................
3*','5"2'
. .................. ............................. .............................................................. * ..................................................
6"0'".6-0,
Total 12 month policy premium and fees
$2,691.52
Important information about fees
You have paid installment fees of $15.00 on this policy. An additional installment fee of $3.00 has been included in each
remaining payment. You may reduce the amount you pay in installment fees by paying your premium in larger amounts
and fewer installments. Please call 1-800-895-2886 for details.
The following additional fees may apply:
Fee for returned checks or refused payments $20.00
0
Foirn6489WOW10)
contlJ11
POLICYHOLDER COPY SC
P.O. BOX 8192, PLEASANTON, CA 94588
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
ISSUE DATE: 08 -30 -2015 GROUP:
POLICY NUMBER: 9104391 -2015
CERTIFICATE ID: 30
CERTIFICATE EXPIRES: 08 -30 -2016
08 -30- 2015/08 -30 -2016
CITY OF EL SEGUNDO SC
ATTN: CITY CLERK
380 MAIN ST
EL SEGUNDO CA 90245 -3813
This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved 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, term or condition 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 iubject to all the terms, exclusions, and conditions, of such policy.
ENdORSEMENT #11300 - BELL, MICHAEL J, PRES SEC TRES - EXCLUDED.
ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 03 -09 -2015 IS
ATTACHED TO AND FORMS A PART OF THIS POLICY,
EMPLOYER
BELL EVENT SERVICES SC
531 MAIN ST # 228
EL SEGUNDO CA 90245
M0409
IREV,7.20141 PRINTED : 07 -17 -2015
Authorized Representative
President and CEO
EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE.
ENdORSEMENT #11300 - BELL, MICHAEL J, PRES SEC TRES - EXCLUDED.
ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 03 -09 -2015 IS
ATTACHED TO AND FORMS A PART OF THIS POLICY,
EMPLOYER
BELL EVENT SERVICES SC
531 MAIN ST # 228
EL SEGUNDO CA 90245
M0409
IREV,7.20141 PRINTED : 07 -17 -2015
ENDORSEMENT AGREEMENT
WAIVER OF SUBROGATION
9104391 -15
RENEWAL
Sc
HOME OFFICE
SAN FRANCISCO PAGE 1 OF 1
ALL EFFECTIVE DATES ARE
AT 1201 AM PACIFIC EFFECTIVE JUNE 2, 2016 AT 12.01 A.M.
STANDARD TIME OR THE
TIME INDICATED AT AND EXPIRING AUGUST 30 , 2016 AT 12.01 A.M.
PACIFIC STANDARD TIME
BELL EVENT SERVICES
531 MAIN ST # 228
EL SEGUNDO, CA 90245
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,
w BELL EVENT SERVICES
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; JUNE 6, 2016 2570
AI I �HOR1EEp REPRESEiT 1118' PRESIDENT AND CEO
SCIF FORM 10217 IREV.7.2014i OLD OF 217