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PROOF OF INSURANCE (2017) CLOSED��0 1 JYYYIQ CERTIFICATE OF LIABILITY INSURANCE DATE (MMlDD3/28/2016 THIS CERTIFICATE 15 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 pollpy'(les) must be endorsed. if SUBROGATION IS WAIVED, subject to the terns 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 Ileu of such endorsoment(s).. PRODUCER �rACT Stephanie Weiss R. Specialty Agency Special Insurance Performers of the U.S. PHONE F. N151t . 715 -246 8908 AtC N,a ; 715- 246A257 P.O. Box 24 D certslspocial lnsuraticeagency.com New Richmond, WI 54017 INSURER 8 AFFORDING COVERAGE NAIc INSURERA; Evanston Insurance Company 35378 INSURED Eric R. Greenberg INSURERS: dba Liberty City 18560 Vanowen St, Unit 14 INSURER C: Reseda, CA 91335 INSURER D: 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. WIN POLICY eFF POLICY EXP... . j--m TYPE OF INSURANCE POLICY NUMBER LIMITS GENERAL LIABILITY i EACH OCCURRENCE S 1,000,000 X COMMERCIAL GENERAL LIARMITY � ��� $ 300.000 PRf.I4IISES' f.a ccur CLANS-MADE E OCCUR - „ -.._.. MEDEXP one arson S 5,000 A X 2CN0140 -2490 04/25/2016 04/24/2017 PERSONAL BADVINJURY S 1,000,000 -^ W •...,- .- ......� GENERAL AGGREGATE $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG S 2,000.000 X POLICY PRA LOC S AUTOMOOME LIABILITY NED MN Me or�ldaslu ANY AUTO BODILY INJURY (Per person) S ALLOSNED SCHEDULED BODILY INJURY (Per nocldent) $ AUTOS HIRED AUTOS NON-OWNED PIPeOrn A E $ AUTOS j an17 s UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS MADE AGGREGATE S DED RETENTIONS S WORKERSCOMPENBATION wCSTATU- OTH AND EMPLOYERS' LIABILITY YIN TSIiT)G IJ. ANY PROPRIETORIPARTNER EXECUTIVE E.L. EACH ACCIDENT S OFFMERIMEMSER, EXCLUDED? NIA (NIAndatargr In NH) E.L. DISEASE - EA EMPLOY $ � 91yo 6 describe Under DESCRIPTION Of OPERATIONS halow E.L. DISEASE - POLICY LIMIT $ A BUSINESS PERSONAL PROPERTY - AGGREGATE S INLAND MARINE DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, H more space Is required) PERFORMER IS A NAMED INSURED AS A MEMBER OF PERFORMERS OF THE U.S.: Eric R. Greenberg dba Liberty City Additional Insured: The City of El Segundo, its officers, officials, employees, agents and certified volunteers are named as additional insured, but only insofar as the operations under this contract are concerned. Fax: 310640 -7720 Attn: Pamelle Roach CERTIFICATE HOLDER CANCELLATION City of El Segundo 350 Main Street, Room 5 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE El Segundo, CA 90245 -3813 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 26 (2010105) The ACORD name and logo are registered marks of ACORD This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE State Or Governmental Agency Or Subdivision Or Political Subdivision: City of El Segundo City Clerk Attn: Recreation & Parks Director 350 Main Street, Room 5 El Segundo, CA 90245 -3813 The City of El Segundo, its officers, officials, employees, agents and certified. ired to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II - Who Is An Insured is amended to include as an additional insured any state or governmental agency or subdivision or political subdivision shown in the Schedule, subject to the following provisions: 1. This insurance applies only with respect to operations performed by you or on your behalf for which the state or governmental agency or subdivision or political subdivision has issued a permit or authorization. However: 2. This insurance does not apply to: a. "Bodily injury", "property damage" or "personal and advertising injury" arising out of operations performed for the federal government, state or municipality; or b. "Bodily injury" or "property damage" included within the "products- completed operations hazard ". B. With respect to the insurance afforded to these additional insureds, the following is added to Section III - Limits Of Insurance: a. The insurance afforded to such additional If coverage provided to the additional insured is insured only applies to the extent permitted required by a contract or agreement, the most we by law; and will pay on behalf of the additional insured is the b. If coverage provided to the additional amount of insurance: insured is required by a contract or 1. Required by the contract or agreement; or agreement, the insurance afforded to such additional insured will not be broader than 2. Available under the applicable Limits of that which you are required by the contract Insurance shown in the Declarations; or agreement to provide for such additional whichever is less. insured. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. CG 2012 0413 0 Insurance Services Office, Inc., 2012 Page 1 of 1 COMMERCIAL GENERAL LIABILITY POLICY NUMBER: " ' N0140 -24'00 MA K EVANSTON INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET WAIVER OF SUBROGATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM SCHEDULE Additional Premium: $ 0 Name of Person or Organization: Any person(s) or organization(s) to whom the Named Insured agrees to waive rights of recovery in a written contract. The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV — COMMERCIAL GENERAL LIABILITY CONDITIONS) is amended by the addition of the following: We waive any right of recovery we may have against the person or organization shown in the Schedule above as respects written contracts that exist between you and such person or entity, provided you have agreed in writing to furnish this waiver. This waiver applies only to the person or organization shown in the Schedule above. All other terms and conditions remain unchanged. MEGL 0241-0104 11 Includes copyrighted material of Insurance Services Office, Inc. with its Page 1 of 1 permission. POLICY ...N 2490 ... -' UMBER 2CN0140- t'oMf tWAL GENERAL LIABILITY CG 20 01 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. fe" , 1� 0 0 0 mi 1 11 mr: 1:1 1:111110 F.-i I I 1:1A ki 1 0 , 1 6 This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS /COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance Condition and supersedes any provision to the contrary: Primary And Noncontributory Insurance This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: (1) The additional insured is a Named Insured under such other insurance; and (2) You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured. CG 20 01 0413 © Insurance Services Office, Inc., 2012 Page 1 of 1 P000003330/C000135270 -007!038- "VIP- A03330 /SEL /1/3 PERSONAL AUTOMOBILE Offer To Renew Declaration effective t POLICY DECLARATION Nov 5, 2015 107SI/fOlice Your coverage expires Nov 05, 2015, at 12:01 A.M. Payment of the premium renews your policy for the period shown. If your payment is not received before Nov 05, 2015 this Offer to Renew will be null and void. ERIC GREENBERG WAWANESA INSURANCE 18560 VANOWEN ST #14 9050 FRIARS RD STE 101 RESEDA CA 91335 SAN DIEGO CA 92108 -5865 Telephone: 1- 800 -640 -2920 Policy Number Account Numba PoIJcy Period 12:01 A.M. standard time at the address of the 11345100 2174251 -1 From Nov 5, 2015 to Nov 5, 2016 Named Insured as stated herein Named insured's Phone Number: 818- 344 -8332 "" ' Named InAvrpd °e Email Addre s- eric @libertycityent,com Your 12 month premium for two (2) vehicle(s) is $2,158.00. Refer to the breakdown of premiums below. Description of Owned Vehicle(s) Vehicle' Year Make Model Vehicle Identification Number Premium per Vehicle ($) 1 2009 Honda FIT JHMGE88229SO59233 1,222.00 _.._. 2013 Hyundai E ............... 2 LANTRA GLS /ELANTRA KMHDH4AE4DU952103 936.00 LIMITED Insurance is provided only with respect to the coverage's for which a Premium is stated, subject to all conditions of the policy. Coverage and Limits of Liability See Policy for Coverage Details Bodily Injury Liability $15,000 per person /$30,000 each occurrence Property Damage Liability $5,000 each occurrence Medical Payments $5,000 each person Comprehensive­ $500 deductible Collis.._... �..... ion $500 deductible Uninsured /Underinsured Motorists Protection $30,000 per person /$60,000 each occurrence Uninsured Motorists Collision Deductible Waiver Total Premium per Vehicle ($) Premiums per Vehicle ($) 1 2 322.00 I 221.00 311.00 1 231.00 88.00 i 59.00 34.00 II 26.00 368.00 1 323.00 85.00 V 62.00 14.00 J 14.00 1,222.00 936.00 Oct 05, 201500:19 CT " Wawanesa Insurance" is a trademark of Wawanesa General Insurance Company September 6, 2016 To Whom It May Concern, Liberty City contracts our various performers on an "as needed" basis for individual events rather than hiring individuals as employees. All of the performers are independent contractors responsible for their own taxes. Since we have no employees we do not provide workman's compensation. Sincerely, Eric Greenberg 18560 Vanowen St. #14 • Reseda, CA 91335 • office: 818 - 344 -6929 • fax: 818 - 344 -6108 w w w. I i b e r t y c i t y e n t. c o m