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PROOF OF INSURANCE (2017) CLOSED
1+� CERTIFICATE OF LIABILITY INSURANCE DA 5 /2 /DO/Y s/2/2016 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 AD15 TIO'NAL INSUREII„ the policy(fes) 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 endorseme 3). INSURED RICHARD WOLOSKI m — Hey Hey Entertainment LLC INSURER C DBA: Hey Hey Entertainment ! qR P: - 3441 Faust Ave. INSVR rr E c w . ,. ....._ ------- .... _ . _ .,. ........ .... Lorin Beach CA 90808 , INS R,ER F : O ftACtES CERTIFICATE t+iUNfEIeR.CL164500235 RE ION NUiMBER;_ THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTVNTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFIGATE DE N IS SUBJECT TO ALL THE TERMS, MAY WBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY TPOLICIES c Y PAID CLAIMS.. HEREIN -� " WWWWWWWWY FXCLUSIO SAND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED Po Y CLAIMS. LIMITS NS V 1 IDOL vdV TYPE OF INSURANCE POCK N MBER p X COMMERCIAL GENERAL LIABILITY ..000,000 EACH OCCURRENCE 1 ,, a w TYAMATsETOR 100,000 A CLAIMS -MADE X OCCUR )?1 EMU jEe� a� S 1, " _ X CONTRACTUAT. LIABILITY _ X N USA- a125SBS 4/9/2016 6/9/2017 'mMED EXP (P4nJ onep_.!SA 3 5,00 0 .. �... C AOVINJURY 'S 000 000 GEN °L AGGREGATE ._..... LIMIT APPLIES PER POLICY PRO- JECT I _ LOC V AUTOMOBILE LIABILITY ANY AUTO ALL OVMED —.•., SCHEDULED NON -OVM M I a HIRED AUTOS ��AUTOS UMBRELLA LIAR I. OCCUR EXCESSLISAO CLAPIS w n N A'Y�9NTlC5na. VWOFXERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR(PARTNERPEXECUI IVE -. '�.� N f A OFF"RIMEMMBER EXCLUDE O9 GENEORALAGGREGATE S 2,000,000 ( PRODUCTS COMPIOP AGG 000 2,000,.... u EL T $ ......... . BODILY URY (Per Person) 5 BODILY INJURY (Par accident) - R4i"ERTYB AGE _ . iPACH OCCURREhRE.IT. , _ a........ _ITITITIT. ... AGGREGATE——, ...... _ _...._ 8 S.ft. UTE _E.L EACHACCIDENT E "L. DISEASE - FA E MP L..iYE ' $ ._ .._....,_ .......... MwwA!tC .CM I`Y IIMIr $ DESCRIPTION OF OPERATIONS d LOCATIONS f VEHICLES (ACORD IOt, Additional Remarks Schedule, may be attached If apace Is requlrod) THE CITY OF EL SEGUNDO ITS OFFICERS, OFFICIALS, EMPLOYEES, AGENTS & CERTIFIED VOLUNTEERS ARE HEREBY NAMED AS ADDITIONAL INSURED AS THEIR INTEREST MAY APPEAR IN THE OPERATIONS OF THE NAMED INSURED WITH RESPECTS TO LIABILITY SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CITY OF EL SEGUNDO PUBLIC LIBRARY THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ATTIN. LIBRARY DIRECTOR 111 W. MARIPOSA AVE. AUTHORIZED REPRESENTATIVE G EL SEGUNDO, CA 90245 Ud_�_ Q 11988.2014 ACORD CORPOOT1001. All rights re I erva ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD INS025 (2owi) Si. t @111 �Plan g PRODUCER _ FAX PHONE (562)594 -6893 Appling Ineuraace Service® . F 10845 BLOOMFIELD STREET w _ L03 INSURER A f1TTT' t" ED SftCIALT. X _ ;l §�C O ftACtES CERTIFICATE t+iUNfEIeR.CL164500235 RE ION NUiMBER;_ THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTVNTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFIGATE DE N IS SUBJECT TO ALL THE TERMS, MAY WBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY TPOLICIES c Y PAID CLAIMS.. HEREIN -� " WWWWWWWWY FXCLUSIO SAND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED Po Y CLAIMS. LIMITS NS V 1 IDOL vdV TYPE OF INSURANCE POCK N MBER p X COMMERCIAL GENERAL LIABILITY ..000,000 EACH OCCURRENCE 1 ,, a w TYAMATsETOR 100,000 A CLAIMS -MADE X OCCUR )?1 EMU jEe� a� S 1, " _ X CONTRACTUAT. LIABILITY _ X N USA- a125SBS 4/9/2016 6/9/2017 'mMED EXP (P4nJ onep_.!SA 3 5,00 0 .. �... C AOVINJURY 'S 000 000 GEN °L AGGREGATE ._..... LIMIT APPLIES PER POLICY PRO- JECT I _ LOC V AUTOMOBILE LIABILITY ANY AUTO ALL OVMED —.•., SCHEDULED NON -OVM M I a HIRED AUTOS ��AUTOS UMBRELLA LIAR I. OCCUR EXCESSLISAO CLAPIS w n N A'Y�9NTlC5na. VWOFXERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR(PARTNERPEXECUI IVE -. '�.� N f A OFF"RIMEMMBER EXCLUDE O9 GENEORALAGGREGATE S 2,000,000 ( PRODUCTS COMPIOP AGG 000 2,000,.... u EL T $ ......... . BODILY URY (Per Person) 5 BODILY INJURY (Par accident) - R4i"ERTYB AGE _ . iPACH OCCURREhRE.IT. , _ a........ _ITITITIT. ... AGGREGATE——, ...... _ _...._ 8 S.ft. UTE _E.L EACHACCIDENT E "L. DISEASE - FA E MP L..iYE ' $ ._ .._....,_ .......... MwwA!tC .CM I`Y IIMIr $ DESCRIPTION OF OPERATIONS d LOCATIONS f VEHICLES (ACORD IOt, Additional Remarks Schedule, may be attached If apace Is requlrod) THE CITY OF EL SEGUNDO ITS OFFICERS, OFFICIALS, EMPLOYEES, AGENTS & CERTIFIED VOLUNTEERS ARE HEREBY NAMED AS ADDITIONAL INSURED AS THEIR INTEREST MAY APPEAR IN THE OPERATIONS OF THE NAMED INSURED WITH RESPECTS TO LIABILITY SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CITY OF EL SEGUNDO PUBLIC LIBRARY THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ATTIN. LIBRARY DIRECTOR 111 W. MARIPOSA AVE. AUTHORIZED REPRESENTATIVE G EL SEGUNDO, CA 90245 Ud_�_ Q 11988.2014 ACORD CORPOOT1001. All rights re I erva ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD INS025 (2owi) UMBRELLA LIAR I. OCCUR EXCESSLISAO CLAPIS w n N A'Y�9NTlC5na. VWOFXERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR(PARTNERPEXECUI IVE -. '�.� N f A OFF"RIMEMMBER EXCLUDE O9 GENEORALAGGREGATE S 2,000,000 ( PRODUCTS COMPIOP AGG 000 2,000,.... u EL T $ ......... . BODILY URY (Per Person) 5 BODILY INJURY (Par accident) - R4i"ERTYB AGE _ . iPACH OCCURREhRE.IT. , _ a........ _ITITITIT. ... AGGREGATE——, ...... _ _...._ 8 S.ft. UTE _E.L EACHACCIDENT E "L. DISEASE - FA E MP L..iYE ' $ ._ .._....,_ .......... MwwA!tC .CM I`Y IIMIr $ DESCRIPTION OF OPERATIONS d LOCATIONS f VEHICLES (ACORD IOt, Additional Remarks Schedule, may be attached If apace Is requlrod) THE CITY OF EL SEGUNDO ITS OFFICERS, OFFICIALS, EMPLOYEES, AGENTS & CERTIFIED VOLUNTEERS ARE HEREBY NAMED AS ADDITIONAL INSURED AS THEIR INTEREST MAY APPEAR IN THE OPERATIONS OF THE NAMED INSURED WITH RESPECTS TO LIABILITY SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CITY OF EL SEGUNDO PUBLIC LIBRARY THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ATTIN. LIBRARY DIRECTOR 111 W. MARIPOSA AVE. AUTHORIZED REPRESENTATIVE G EL SEGUNDO, CA 90245 Ud_�_ Q 11988.2014 ACORD CORPOOT1001. All rights re I erva ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD INS025 (2owi) DESCRIPTION OF OPERATIONS d LOCATIONS f VEHICLES (ACORD IOt, Additional Remarks Schedule, may be attached If apace Is requlrod) THE CITY OF EL SEGUNDO ITS OFFICERS, OFFICIALS, EMPLOYEES, AGENTS & CERTIFIED VOLUNTEERS ARE HEREBY NAMED AS ADDITIONAL INSURED AS THEIR INTEREST MAY APPEAR IN THE OPERATIONS OF THE NAMED INSURED WITH RESPECTS TO LIABILITY SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CITY OF EL SEGUNDO PUBLIC LIBRARY THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ATTIN. LIBRARY DIRECTOR 111 W. MARIPOSA AVE. AUTHORIZED REPRESENTATIVE G EL SEGUNDO, CA 90245 Ud_�_ Q 11988.2014 ACORD CORPOOT1001. All rights re I erva ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD INS025 (2owi) POLICY NUMBER: USA - 4125884 COMMERCIAL GENERAL LIABILITY CG 2010 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Oruanization(s); . lies as a real OEM to complete this Schedule , ")f A. Section ll — Who Is An Insured is amended to Include as an additional Insured the person(p) or orga�nlzation(s) shower In the Schedule, but only with respect to Viability for "bodily Injury", „property damage "' or "personal and advertising Injury*' caused, in whole or in part, by: 1. Your'acts or omissions; or, 2. The acts or omissions of those acting on your behaff;, In the performance of your ongoing opefations.tor the additional Insured(s) at the, location(s), desig- nated above. CITY OF EL SEGUNDO PUBLIC LIBRARY• ATT "N. LIBRARY DIRECTOR 111 W. MARIPOSA AVE. EL SEGUNDO, CA 90245 CG 20 10 07 04 All Insured premises and operatioi 6 ,' i6 will be shown in the B. With respect to the insurance afforded to these additional insureds, the following additional exclu- sions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, Including materials, parks or equip- inept furnished In;connept dn,wit •,such work, on the project (other than service, maintenance or repaiirs) to be performed, by or on behalf of the additional insureds) at the location of the covered operations has been completed; or 2. That portion of "your work out of which the Injury or damage arises has been put to its in- tended use by any person, or organization oth- er than another contractor or subcontractor engaged in performing operations for a prin- cipal as a part of the same project. © ISO Properties, Inc., 2004 Page 1 of 1 D 4/29/2016 To whom it may concern, Regarding my gig on June 14th at the El Segundo public Library. I am self - employed and do not have workman's comp. insurance. I have no employees. Richard Woloski Hey Hey Entertainment heyheyentertainment @ yahoo.com