PROOF OF INSURANCE (2016) CLOSED' °2601'4` M CERTIFICATE OF LIABILITY TY I SURA CE 09 //2
114�.
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 ADDITIONAL INSURED, the pollcy(les) must be endorsed. if SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain pol'ici'es may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in Ileu of such endorsement(a).
PRODUCER
Eat! T
HCC Specialty
PHONE
401 Edgewater Place, Suite 400
Wakefield, MA 01880
-
- - -• —
INSURER(S) AFFORDING COVERAGE
NAIL Ir
INSURED
INSURERA: New Hampshire Insurance Company
v
23841
Ultimate Jam Band
INSURERS: United States Fire Insurance Com an
21113
1001 W. Lambert Road #287
INSURERC:
__. w ._._.m _.... __ . __..__....._ _ ...__._::
L.._.......... ,
La Hambra, CA 92833
INSURERD:
INSURERE:
INSURER IF
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,
INOR 17— TYPE OF INSURANCE I yyyp POLICY NUMBER
POLICY % POLICY EXP
MWDD/Y WDD9Y YY LIlARB
GENERALUABILITY
A X SEL014581189
X COMMEFICIALG'ENERALLABILITY
I EACH OCCURRENCE $
09/2912016 11/03/2016 fls�
� t
1,000,000
300,WO
CLAIMS -MADE X OCCUR
msgfti
5,000,
X Host Liquor
PERSONAL A ADV INJURY S
1,000,000
B X Medical Expense US752537
09/29/2016 11/03/2016 GENERAL AGGREGATE S
2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGO $
1,000,000
X POLICY ,PICT LOC
S
AUTOMOBILE LIABILITY
COWBI14ED SINGLE LIMB S
�w
(Ea accident)
ANY AUTO
BODILY INJURY (Per person) S
ALLOWNEDAUTOS
BODILY INJURY (Per accident) 5
SCHEDULED AUTOS
PROPERTY DAMAGE S
HIRED AUTOS
(Per accident)
NON -OWNED AUTOS
=
i
UMBRELLA LIAR OCCUR
EACH OCCURRENCE 5
EXCESSLIAB CLAIMS -MADE
AGGREGATE $
DEDUCTIBLE
S
RETENTION
i
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY YIN
ANY PROPRIETORMARTNER/EXECUTIVE r-1
E.L. EACH ACCIDENT S
OFFICER/MEMBER EXCLUDED?
(Mandatory In NH)
E.L. DISEASE - EA EMPLOYE
II es, dasculgra under
R T' F P RA-n w
E.L. DISEASE - POLICY LIMIT S
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional RsmarksSehadWs, Hcoon spaes la raquhad)
The Cer0cola Folder Is added as Additional Insured *M respects to our Insur Ws operations oMy.
TNs Insurance Is pdnwy and non-contributory n required by wrltlen contract.
TMs coverage N with respect to IS Seq ndo Halloween Frolc avant to be hold 1013112016.10/3112016 at City of EI Segundo E1 Segundo CA
Ir
City of El Segundo, its officers, officlals, employees, agents, and
Volunteers
350 Main Street
El Segundo, CA 90245
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED
IN ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTAT
ACORD 25 (2010106) ®1988.2010 ACORD CORPORATION. All rights reserved.
POLICY NUMBER: 14581189 COMMERCIAL GENERAL LIABILITY
CG 20 26 0413
Name Of Additional Insured Porson(s) • Organ ization(s):
City
• El Segundo, its officers, officials, e.mployees, agents, and volunteers, 350 Main Street, El Segundo, CA,
mnolm=
this Schedule, if
B, With respect to the insurance afforded to these
additional insureds, the following is added to
Section III — Limits Of Insurance:
whichever is less.
This endorsement shall not increase the
applicable Limits of Insurance shown in the
Declarations,
CG 20 26 04 13 Q insurance Services Office. Inc., 2012 Page I of *'
Western Horne IIISUrance Company
AdinmnOzicrea o,,
L(��qacy Pa'-N'7c
P 0 Box 50600
F3 E N E VV A, I A, ITO Rii )LACY D!! C LA F!? A, T1 0 tJ S
N1 A M D I 11,I S V J F? E0
Bl!'Ibb,V Johnsoin
1001 �1%,' Il , aiirbeOi Rd Spc 28",
1, )pQ
a Habil a C) t,� �),,
Poky Nurnber,CAWA- 000154729
rcr,cd March 30. 2016 to
March 30, 2017 at 12 01 A10
5F-2 a,�
P r u r 11 r P u!! y II "10,
Pii'oi!:essecI DWe
pat II rch 20 16
Page 1 Of I
This Dec aralions page along with "PoHcy Provisions" and any other app flcabpe endorsements cornp etes your poft'.
Dhve
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C orrIc c,:z I Z-[ W,
LINUT Unit I Unit L) nit
P11 OR0UM
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In regarding any ancrease Ln preniturn dUe to the involvement in any chargpab�e accidents or convictions ca
be obta�ned upon request by contacling L(,iq-acy Cuslorner Serv�ce, (= 3B1 A & 489)
Ccidmn,er �\A w ch 29 � 2016 By
ORGNAL S Ij 1,:: C'1 �
1 I „ - P"
• kp
1
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.
(_) 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:
l Carrier Policy Number Expiration Date
Name of Agent Phone #�
X MI certify that, in the performance of the work set forth in the agreement with the City of EI Segundo. I will not
loy any person in any manner so as to bec rn subject to the workers' compensation laws of California, and
agree that, if I should become subject tie yrc c�°s" compensation provisions of Labor Code § 3700 1 must
immediately comply with those provision dr i,a"ftrp nient will automatically become void.
Signature of Applicant
Agreement for: C IqL�A'
Dated: N
wm
Reviewed by:
Date