PROOF OF INSURANCE (2016) CLOSEDDATE(MBArDDIYYYY)
CERTIFICATE OF LIABILITY INSURANCE 06/27/2016
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: It the certificate holder is an AI)DITIONAE I9SUR96, the prollcy('le -s) must be endorsed. If SUBROGATION IS WANED, sublect lb
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer right's to the
certificate holder In lieu of such ondorsornent(s).
PRODUCER
HCC Specialty PH NE Art:
401 Edgewater Place, Suite 400 CDR
UCER
Wakefield, MA 01880 e A,
INSURERISI AFFORDING COVERAGE NAIC ■
Yevmku
INSURERA:
1Vew rlarlpanlre
Albert Kim (TENN WEST)
INSURERS:
µ United States Fire
1120 6th St Unit B
INSURER C:
„AIMS.
Hermosa Beach, CA 90254
_u+auRERD z_....,e,m_...m._
�..e._._._...
S
INSURERE:
MISTED
E L—
i
INSURERF:
:OVERAGES CERTIFICATE NUMBER:
5,000
RE
Y4HIOH THIS CERTIFICATE MAY SE ISSUED OR MAYxPEFITAIN, "THE NNSUIiANCE APFORDEO BY THE POLICIES DESCRIBE
TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY
A GENERA M AOIAL X SEL064082867 06/27/2016 07/13/2016
X COMWtER�aIALFRENiER9Al :I,IASAbTY
CLAIM&MADE a] CCCUR
X Host Liquor
B Medical Expense USS76043 06/27/2016 07/13/2016
GENL AGGREGATE LIMIT APPLIES PER:
i POLICY P LOC
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON -OWNED AUTOS
UMBRELLA LIAR OCCUR
EXCESSLIAD CLAIMS
DEDUCTIBLE
AND
YIN
F-1
DESCRIPTION OF OPERATIONS I LOCATIONS r VEHICLES (Attach ACORD 101, Adeftnul Remarks Schedule, It mote space Is required)
The Conacale Holder is added as Addth" Insured wah respeds to our Insumd's oper9wo sdy.
TNs Insuranm Is p4mry and nar•mnbieutay a roquh by w hien contract.
This coveMe is wkh reaped to ® Sal do City teacart• Library Park event to be held 711012018.71102010 at Lbmry Park El Bewrido CA
City of El Segundo, its officers, officials, employees, agents, and
Volunteers
350 Main St
El Segundo, CA 90245
ACORD 26 (2010105)
nee CDmpan 21113
I NUMBER:
:OR' THE POLICY
T WITH AESPEC'T TO
Rte IS SUBJECT
„AIMS.
Warr$
IRREWE
S
1,000,000
MISTED
E L—
i
300,000
5,000
LAOVINJURY
S
1,000,000
S
COMBINED SINGLE LIMIT S
Me aoddan8
BODILY INJURY (Per perwM 13
BODILY INJURY (Par aedderrq S
PROPERTY DAMAGE s
(Per aeddem)
S
S
EACHOCCURRENCE S
AGGREGATE S
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF NOTICE WILL BE DELIVERED
IN ACCORDANCE WITH THE POLICY PROVI )ONS,
AUTHORIZED REPRESENTAT
01988 -2010 ACORD CORPORATION. All rights reserved.
POLICY NUMBER: 64082867
COMMERCIAL GENERAL LIABILITY
CG 20 26 0413
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - DESIGNATED
PERSON OR ORGAIIZATIOwI.
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
350 Main St.
El Segundo, CA 90245
,z *lam_-
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 " 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
provide for such additional insured.
In the Declarations.
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 0413 0 Insurance Services Office, Inc„ 2012 Page 1 of 1
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°% HAT TOD IN CASE or AN ACCIDENT:
Contact Farmers ClaW Department
Call us 24•flours allay at (SOD)435•7764
Pnra ESpnrlol, flame al (SM 732.5266
obtain the followlnp mformab®n:
I Haree, addres. and plAnenumberof each drr %w.pa✓vlger and ATtnass
2 Urrcr'. lccF— wr oxnber, vehicle drinpuona�idlceracpiatenirrber:
3 Vah.clodwrlagealdacadmi scene
pl »Ica
11. Name ct Iro lran a corraanV and polr_y nurnter for each Vehicle
S, kporl Iha accident to the p(op.: a,llhwraos
6 Uo not ad•rlil (aull - an Imc :Ugaboa may LY.er rcvci }m1 •Acre not
rc%ponmmle for the acc►dore
Vl,t. ., I.0 li'•I tolcarnrlorcaboutclarn .cif- ulYaaopuorc it's
quick, comrnr.•nl and alai }. uyenl
Svc polay for lxfua 'caveragrlonliwaW, ."Al, lu
The Colilnrnla Department of Motor Vehldes (DMV) requires praol
of insurance when registering your vehicle
Please provide this form to the I)MV vithen teg 151er1ng your Vehicle,
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