PROOF OF INSURANCE (2016) CLOSEDCity of El Segundo, Its officers, officials, employees, agents, and
volunteers
SHOULD ANY OF THE ABOVE DESCRIBED POUCISS aE CANCELLED
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ACORD 25 (2010108) ®1088 -2010 ACORD CORPORATION, All rights reserved,
POLICY NUMBER: 64082359
COMMERCIAL GENERAL LIABILITY
CG 20 26 0413
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - DESIGNATED
PERSON OR ORGANIZATION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person(s) Or Organization(s):
As submitted to company and required by written contract.
City of El Segundo, Its officers, officials, employees, agents, and
volunteers
this Schedule. If not shown
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 e' 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
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
provlde for such additional Insured.
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.
CO 20 26 04 13 0 Insurance Services Office, Inc., 2012 Page 1 of 1
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:
(_) 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.
(__) 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 Policy Number Expiration Date
Name of Agent Phone #
Cj 3 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 kbJect to the workers' compensation provisions of Labor Code § 3700 I must
immediately comply with those p ohe agreement will automatically become void.
Signature of Applicant Date
JeArl
Agreement for:
Dated:
Reviewed by:
L-J--
Main street
(Vintage Band)
Date: 5 -26 -16
TO: City of El Segundo
Re: Business Automobile Liability Insurance and Worker's Comp
I, Jean -Louis Boudreau, band member of Main Street Band, certify that all band members are
Independent contractors.
The band is not incorporated and does not carry Business Automobile Liability Insurance.
Thank
Boudreau
406 Maryland Street * Ell Segundo CA 90245 * tel: 310.720.9360 # fax: 310.726.0138