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PROOF OF INSURANCE (2017) CLOSED CERTIFICATE OF LIABILITY INSURANCE DAT1/12/2017 D/YYYY) 1/12/2 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 LEAVITT INSURANCE AGENCY OF SAN DIEGO NAME: 380 STEVENS AVE STE 115 (A/C..N ,Extl: ('8581519 32'1p � t FAX N�1, (858)259-6069 SOLANA BEACH,CA 92075-2068 EMAIL ADDaES : (858)519-3210 INSURER(S)AFFORDING COVERAGE NAIC# .�.................................................... INSURERA: United States Fire Insurance 21113 INSURED SPORTS AND RECREATION PROVIDERS ASSOCIATION(PURCHASING GROUP)AND INSURER ; ITS PARTICIPATING MEMBERS: INSURER C: Rusty Frank DBA Lindy By The Sea, Rusty's,On Tap INSURERDc 225 Whiting Street El Segundo,CA 90245 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: USP201650 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. INiSR TYPE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR WVD (MMIDD/YYYY) (MM/DDIYYYY) GENERAL LIABILITY GENERAL AGGREGATE $1,000,000.00 X COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG $1,000,000.00 CLAIMS-MADE PERSONAL&ADV INJURY $1,000,000.00 A — X SRPGP-101-0715 01/21/2016 01/21/2017 EACH OCCURRENCE $1,000,000.00 ...�... 12:01 AM 12:01 AM FIRE DAMAGE(Anyone fire) $300,000.00 7r-611 AGGREGATE LIMIT APPLIES PER: I MED EXP(Any one person) $0.00 POLICY —1 PRO- N ^LOC — AUTOMOBILE LIABILITY I COMBINED SINGLE LIMIT lEa accident) $ .ANYAUTO I BODILY INJURY(Per person) $ .. ALL OWNED SCHEDULED I BODILY INJURY(Per accident) $ AUTOS AUTOS II HIRED AUTO NON-OWNED PROPERTY DAMAGE AUTOS (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB ; CLAIMS-MADE AGGREGATE $ DED I RETENTION $ EACH OCCURRENCE $ GENERAL AGGREGATE $ EACH OCCURRENCE $ GENERAL AGGREGATE $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) The City of El Segundo,its officials,and employees are added as an additional insured but only with respect to liability arising out of operations of the named insured during the policy period. Covered Activity:Swing Dancing,Partner,Tap Dancing Coverage is Primary Non-Contributory CERTIFICATE HOLDER CANCELLATION City of El Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN El Segundo City Hall ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street El Segundo CA 90245 AUTHORIZED REPRESENTATIVE Leavitt Insurance Agency of San Diego I ACORD 25(2010/05)v141120.001 ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD COMMERCIAL GENERAL LIABILITY CG 20 26 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OIL ORGANIZATION Policy Number: SRPGP-101-0715/USP201650 Insured: Rusty Frank DBA Lindy By The Sea, Rusty's, On Tap This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) City of El Segundo El Segundo City Hall 350 Main Street El Segundo CA 90245 Information required to complete this Schedule, if not shown above will be shown in the Declarations. To the extent that any of the additional insureds Section II - WHO IS AN INSURED is amended to named herein are liable for occurrences arising out include as an insured the person(s) or organization(s) of the named insured's negligent acts or omissions, shown in the Schedule, but only with respect to liability the insurance afforded to the additional insureds for "bodily injury", "property damage" or "personal and under this endorsement is primary insurance over advertising injury" caused, in whole or in part, by your any other valid or collectible insurance which the acts or omissions of the acts or omissions of those additional insureds may have with respect to loss acting on your behalf: under any of the listed policies. Other insurance of any additional insured applicable to loss is non- contributory and excess over the coverage provided A. In the performance of your ongoing operations; or by this endorsement, and the amount of the B. In connection with your premises owned by or company's liability under this policy shall not be rented to you. reduced by the existence of such other insurance. 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