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PROOF OF INSURANCE (2017) CLOSED DATE(MM/DD/YYYY) C" CERTIFICATE OF LIABILITY INSURANCE I 12/19/2016 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: If the certificate holder is an ADDITIONAL INSURED, the pOicy(ies) 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 endorsement(s), PRODUCER CONTACT Trevor Drake NAME: Brown & Brown of PA PHONE (484)567-0150 FAX (484)567-0158 (A(C,,,No,EXt): (AIC';,No): 125 E Elm Street E-MAIL ADDRESS:name @bbof P a.com Suite 210 INSURERS)AFFORDING COVERAGE NAIC# Conshohocken PA 19428 INSURER,A:Philadelphia Indemnity Ins Cc 18058 INSURED INSURER B Patrick Connor, DBA:Fantastick Patrick Productions INSURER C: 11131 Rose Ave, #13 INSURER D: INSURER E: Los Angeles CA 90034 INSURER F: COVERAGES CERTIFICATE NUMBER:16 - 17 Liability 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, INSIR TYPE OF INSURANCE IDOL WVD POLICY NUMBER (IWPM CdD Y EFF I POLICY EXP LIMITS � ICfYYYYY (MM'd'DDdYYYYY X COMMERCIAL GENERAL I OCCUR I DAMAGE PREMISES RENTED $ 1/100,000 A CLAIMS-MADE X ( ) X PHPK1430407 1/29/2016 1/29/2017 MED EXP(Any one person) $ 0 PERSONAL&ADV INJURY $ 1,000,000 N'LL AGGREGATE LIMIT APPLIES PRODUCTS AGGREGATE $ 2,000,000 X LOC RDucrs-COMP/OP AGG $ PRO' 0 2,000,000 01HB°R $ AUTOMOBILE LIABILITY COMBINED SiNGLYF:LIMIT $ (E�Yoc,ydent), ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPER f Y DAMAGE $ AUTOS (Per accident) $ UMBRELLA LIAR OC AIMS-MADE AGGREGATE RRENCE I$ EXCESS LIAB � $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER„ ANY PROMS NH)EXCLUDED' E L DaSEASECIEA $ OFFICER/MEMBER EY.CLUDED? N/A (Mandatory EMPLOYEE,$ If DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT Y DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Membership ID#: B160201 City of E1 Segundo;Recreation and Parks Department have Additional Insured status per attached form CG-2010, which is included in the policy, while the Named Insured is "on premises". CERTIFIC'A'TE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of El Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Recreation and Parks Department ACCORDANCE WITH THE POLICY PROVISIONS. 401 Sheldon St El Seguundo, CA 90245 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 ont4nn POLICY NUMBER: PI3PKl430407 COMMERCIAL GENERAL LIABILITY CG 20 10 0413 THIS r . ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART f SCHEDULE s w....._ .. ._........................ .._........, erat ,,, ...,.. Or Or anrzatio s Name O Additional Insured Person n� ) Location ons s Of Covered Op_.._,...„' Any persons or organizations as required by written contract executed prior to a ,Loss. [.Information rw uired to c errs a1,dule if not shown above,will be shown in the Declarations. A. Section II — Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured the person(s) or addition-M insureds, the following additional orgzanizalion(s) shown in the $chedule, brat only exclusions apply: with respr;ct to liability for "bodily injuiy” "property This insur once does riot aapply to "bodily injury„ or ( ,arnag,e" or "porsonaal and r,ulvertising Injury" d anu,.i e"occrarr'iraa after: caused. In whole car in part, fay; property ''° 9 �;� 1. Your acts or omissions; or 1. All work„ including materials, parts or equipment furnished in connection with such 2. The acts or omissions of those acting on your work, on the project (other than service, behalf, rruaiva'tenranco or re4),a4s) to tuc-a g,(Irformed by or in the performance of your ongoing operations for on biuh<atf of the a,rdc'litiional Insored('s) at the the additional insured(s) at the location(s) location of the covered opu:r,alions has been desigrmr led above. completed;or However: 2. That portion of "your work" out of which the injury or damage arises has been pout fc,.ii sits 1. The insurance afforded to such additional intended use by any person or or°gl,•anizaa,tion insured only applies to the extent permitted by other than another contractor or subcontractor law; and engaged in performing operations for a 2. If coverage provided to the additional insured is principal as a part of the same project. 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. CG 20 10 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 2 'mm LAI L co m Ln Z gz F- LL u u' 0 SLO o � � � 8 0 go 2 En wZ ""low � Qrr " wLu !--ij!"11,11111111, w � VIII ui o ce (n cc(n > � � Ln LU z cc Liu c) u JC W " w 0 z Cr 72i lllj�Q MU 0 cc 0 � 0 no CL u 2 :D o z .�� w 4, „ c ZZ . +�w uuu,v p' La ,1�NN 0 LL � 0 CL mu°w„!uum m 'N' C m,.. CITY OF EL SEGUNDO WORKERS' COMPENSATION DECLARATION WARNING:FAILURE TO SECURE WO�RK,ERS'COM'P'ENSATION COVERAGE 1 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 PROVIOEO FOR IN LABOR CODE$ 3705, INTEREST, AND ATTORNEY'S FEES. erfirm undefpanalty of periury undw the laws of Cadlfomia one of the following decl'arabws: )I have and will rnainWn a cartiftate o1consent of wb'-insure tot workers' oompensation,Issuod bey the Direclof of IndufArWi Relaillons as pnwidod for by Labor Cade§3700 tot the Wa(m of the work set forth the a, ant Dail the City of El 3apundo. Fbiicy No. � U I haw and will maintainworkers:'componso0on insurance as required by tabor Code;3700 for the performanoe of Ov work r which the aroornent wNh the City of EI Segundo Is ox oouted. Mywotuars'compersation hmmom ewriar and policy number e: Carrier Policy Number Expiration Deb Nome of Agent Ph I I i e ecertify thal, in the pedoniname of tho w set foo In the egreemont worth the City of El Segurdo, I will not L pkoy any person In any manner so as to b000rne subjoet to the penaa#on lows of Cahtor and agree ftt, tf I should becowow Jed to wa efs� compansatlon provisions of Labor Lode § 3,700 1 must t comply with lhoa I agreement will autornoticalty bewme J void. Signature of Applicant Ist"o Agreemot for: AT-4- Dated: a Reviewed