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PROOF OF INSURANCE (2017 - 2017) CLOSED O CERTIFICATE OF LIABILITY INSURANCE I DA 01(/16/2017) 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 policy(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 NAME: Robert V. Nucclo PHONE FAX awPpOrtrt+rcaG 3 (�rc,ra C88 , G7-1, R.V. Nuccio&Associates Insurance Brokers, Inc. 800 364-24 Om 10148 Riverside Drive Ci0,0 Toluca Lake, CA 91602 INSUR ER(S)AFFORDING COVERAGE NAIL#„ ., INSURERA: Fireman's Fund Insurance Company 21873 INSURED INSURER B: VOX DJs INSURER C: 500 S. Sepulveda Blvd#211 INSURER D Manhattan Beach , CA 90266 INSURER E: INSURER F: 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 iLA�:S ... .. f POLICY EFF (MMI POLICY EXP .i.. .. .. LIMITS ( TYPE OF INSURANCE POLICY NUMBER IMMIDD/VYXV -IMMIDDtYYYYI GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 ✓ Co CLAIMS-MADE ✓ accuR PREMISE ` . W ✓ PEVD06 64619 11/15/2016 11/15/2017 P E ISE(Any one person) $ 100,000 COMMERCIAL GENERAL LIABILITY S(Ea oocurr�adio,�c ) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS COMPO'PAGO $ 2,000,000 ✓ ( POLICY ,r;p; LOG, $ AUTOMOBILE LIABILITY COhMBiNED SINGLE LIMIT A ✓ XPK80968969 11/15/2016 11/15/2017 tF0K)ldfk"tly $ 1,000,400 ANY AUTO PEVD062641 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED ( ) AUTOS AUTOS BODILY accident) $ ✓, HIRED AUTOS ✓ �� NON-OWNED (Per dP k TP UAMA6E .de $ AUTOS UMBRELLA LIAB OCCUR I EACH OCCURRENCE $ EXCESS LAB CLAJMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION WC STA"f U- OTH- AND EMPLOYERS'LIABILITY y I N TORY LIMITS I, ER ANY CUTIVE r—� OFFICERIMEMBERIEXCLUER/E E E L EA H A I�NIA (Mandatory in NH) EL DISEASE-E EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE•i1OLICY LIMIT $ u DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Additional Insured: El Segundo City Hall its officials, and employees as"additional insureds" Description: Various Start Date: 1/18/2017 End Date: 11/15/2017 Start Time: 12:00am End Time: 12:00am CERTIFICATE HOLDER CA'NCELLATIO'N El Segundo City SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. El Segundo ,CA 90245 AUTHORIZED REPRESENTATIVE Robert V. Nucclo ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD ISO I Commercial General Liability Forms 101/01/96 POLICY NUMBER: XPK80968969 COMMERCIAL Certificate Number: PEVD062641 GENERAL LIABILITY Effective Dates: 11/15/2016 to 11/15/2017 CG 20 11 01 96 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - MANAGERS OR LESSORS OF PREMISES This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE 1.Designation of Premises(Part Leased to You):, 350 Main Street El Segundo ,CA 90245 2.Name of Person or Organization(Additional Insured): El Segundo City El Segundo City Hall its officials, and employees as"additional insureds" 3.Additional Premium: $0.00 (If no entry appears above,the information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) WHO IS AN INSURED(Section II)is amended to include as an insured the person or organization shown in the Schedule but only with respect to liability arising out of the ownership,maintenance or use of that part of the premises leased to you and shown in the Schedule and subject to the following additional exclusions: This insurance does not apply to: 1.Any 'occurrence"which takes place after you cease to be a tenant in that premises. 2. Structural alterations,new construction or demolition operations performed by or on behalf of the person or organization shown in the Schedule. CG 20 11 01 96 NASEPWH055.doe 0 Insurance Services Office,Inc.,1994 Policy Number: XPK80968969 Certificate Number: PEVD062641 Effective Dates: 11/15/2016 to 11/15/2017 Primary, and Noncontributory- Other Insurance Condition CG 20 01 04 t; Policy Amendment(s) Commercial General Liability 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 (1) The additional insured is a Named Insured under Condilion and supersedes any provision to the such other insurance; and contrary: Primary And Noncontributory Insurance (2) You have agreed in writing in a contract or agreement that this insurance would be primary This insurance is primary to and will not seek and would not seek contribution from any other contribution frond tiny, other insurance available to an additional insured tilt<Ier your policy provided that: insurance available to the additional insured. This Form must be attached to Change Endorsement when issued aflei'the policy is written. One of the Fireman's Fund Insurance Companies as named in the policy A, '�t4w.1 . j6 .. SLCrelary f'reaidew CG2001 4.13 + Insurance Services Ofllee,Inc„ 2012 POLICYHOLDER COPY SC STATE COMPEN5ATION P.O. BOX 8192, PLEASANTON, CA 94588 FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 01-19-2017 GROUP: POLICY NUMBER: 9156249-2016 CERTIFICATE ID: 14 CERTIFICATE EXPIRES: 04-05-2017 04-05-2016/04-05-2017 THIS CERTIFICATE SUPERSEDES AND CORRECTS CERTIFICATE # 13 DATED 01-19-2017 EL SEGUNDO CITY HALL SC 350 MAIN ST EL SEGUNDO CA 90245-3813 This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon 10 days advance written notice to the employer. We will also give you 10 days advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy. �l Authorized Representative President and CEO EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2017-01-19 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: EL SEGUNDO CITY HALL EMPLOYER VOX DJS SC 500 S SEPULVEDA BLVD STE 211 MANHATTAN BEACH CA 90266 [P14,HO] (REV.7-2014) PRINTED 01-19-2017 WAIVER OF SUBROGATION NOTICE Enclosed is your copy of a certificate of insurance on which the certificate holder required a waiver of subrogation: 1. Please be advised that a waiver of subrogation requires that a 3% surcharge will be applied by State Fund ONLY to the premium assessed on the payroll of your employees earned while engaged in work for that certificate holder who requested the waiver. (Note: if you have no employee payroll on that job, then there is no charge.) 2. To apply the 3% surcharge, you must also agree to maintain accurately segregated payroll records for employees engaged in work on job/s for the certificate holder who has the waiver. The payroll records are subject to verification by an auditor. Example: Payroll for job: $5 , 000 . 00 Sample Rate : 13 . 30% Regular Premium equals : $ 665 . 00 Surcharge : 3 . 00% Additional Waiver charge : $ 19 . 95 Total premium equals $ 684 . 95 (665 . 00 + 19 . 95) ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION REP 04 STATE 9156249-16 NEW INSURANCr SC FUND PAGE 1 HOME OFFICE SAN FRANCISCO EFFECTIVE JANUARY 19, 2017 AT 12 . 01 A.M. ALL EFFECTIVE DATES ARE AND EXPIRING APRIL 5, 2017 AT 12 . 01 A.M. AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME KACE ENTERTAINMENT INC, DBA VOX DJ 500 S SEPULVEDA BLVD STE 211 MANHATTAN BEACH, CA 90266 ANYTHING IN THIS POLICY TO THE CONTRARY NOTWITHSTANDING, IT IS AGREED THAT THE STATE COMPENSATION INSURANCE FUND WAIVES ANY RIGHT OF SUBROGATION AGAINST, EL SEGUNDO CITY HALL WHICH MIGHT ARISE BY REASON OF ANY PAYMENT UNDER THIS POLICY IN CONNECTION WITH WORK PERFORMED BY: KACE ENTERTAINMENT INC: DBA VOX DJ IT IS FURTHER AGREED THAT THE INSURED SHALL MAINTAIN PAYROLL RECORDS ACCURATELY SEGREGATING THE REMUNERATION OF EMPLOYEES WHILE ENGAGED IN WORK FOR THE ABOVE EMPLOYER. IT IS FURTHER AGREED THAT PREMIUM ON THE EARNINGS OF SUCH EMPLOYEES SHALL BE INCREASED BY 03%. NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: JANUARY 23, 2017 2570 AUTHORIZED REPRESENT IVE PRESIC7ENT AND CEO SCIF FORM 10217 (REV.7-2014) OLD DP 217