PROOF OF INSURANCE (2017) CLOSED ZEBRA-1 OP ID:JJ
CERTIFICATE OF LIABILITY INS I' NCE � DATE(MMI 02111/2D016,
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(les)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 ��H A CT Dick Wardlow Ins Brokers
Uc k#WB99B o Insurance Brokers 1+E 805-55 3-0605 q 805553-0606
233 High Street Moor�rark CA'9'3021 RESS:
Diick'VlParalOW Ins Brokers I INSURER(S)AFFORDINGCOVERAGE I NAIC0
INSURER A;Essex Insurance Company
INSURED Zebra Entertainment and Events INSURER B: I
Shelly Mazer d
11024 Balboa Blvd#118 I INSURER C;
Granada Hills,CA 91344 INSURER D! I@
I
INSURERS:
INSURER F: I
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.
VLNSR auuL WISH� 11 ifL14Y'E' POLICY CXP
TYPEOFIMSURANC'E POLICY NUMBER )MMJTyD I fMMMDOPfitYYI LIMITS
GENERAL LIABILITY EACH OCCURRENCE u S 1,000,00
COMMERCIAL GENERAL LIABILITY X 3DS5451-M908694 02108!2016 02f0612017 I PREMISES Eoocczirr q ul S 100,00
�1I CLAIMS-MADE F1 OCCUR MED EXP(Any one person) S 5,00
PERSONAL RAOVINJURY S 1,000,00
GENERAL AGGREGATE Is 2,000,00
GEN''L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP-OPAGG IS 1,000,00
IPROM
POLICY J LOC I Deduct II s 1,00
AUTOMOBILE LL48HJTY COMBINED INULE LIMIT' I S
ANY AUTO BODILYINJURY(Perpersm) IS
ALL �OESDULED BODILY INJURY(Per ecddent) S
NON-OWNED lwil�Y'DAMAGE S
HIRED AUTOS AUTOS MENTT
S
UMBR ELLA LAB OCCUR II EACH OCCURRENCE S
EXCESS LIAR I CLAIMS-MADE I AGGREGATE $
DED I J RETENTIONS S
WORKERS COMPENSATION WC STAT'U- T I.
N
AND EMPLOYERS'LWBILIT1 (TORY LIMITS IOFR
ANY PR'OPRIETORMARTNERWEXECUTIVE YIN N I A E.L.EACH ACCIDENT $
OFFICERIMEMBER EXCLUDED?
(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S
1 y0o dosex bo undw
OES 'RIPTIONOF'OPERATIONS beloww E L DISEASE-POLICY LIMIT S
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Addlllonal Remarks Schedule,Ir more space Is ngWnd)
The City of El Segundo, its officers, officials, euployess, agents and
volunteers are narmQd as Addrl Insureds, but only insofar as the operations
under this Written Contract are concerned. This Policy is Primary a Non-
Contributory.
All Event Dates.
CERTIFICATE HOLDER CANCELLATION
CO-ES00
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,
City of El Segundo ACCORDANCE WITH THE PO CY PROVIS ON8E WILL BE DELIVERED IN
350 Main Street
El Segundo,CA 90245 A"
UTMORaED REPRlAP.NTATIVE
llwa
01968-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010106) The ACORD name and logo are registered marks of ACORD
Policy Number:3DS5450-M908894 COMMERCIAL GENERAL LIABILITY
CG 20 26 07 04
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - DESIGNATED
PERSON OR ORGANIZATION
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
Its Officers,Officials,Employees,
Agents and Volunteers
350 Main Street
El Segundo,CA 90245
Information required to complete this Scheduie,if not shown above,will be shown in the Declarations..
Section II — Who Is An Insured is amended to in-
clude as an additional Insured the person(s)or organi-
zation(s)shown In the Schedule.but only with respect
to liability for "bodily injury" "property damage'" or
"personal and advertising injury" caused, in whole or
In part..,by your acts or omissions or the acts or omis-
sions of those acting on your behalf:
A. In the performance of your ongoing operations;or
B. In connection with your premises owned by or
rented to you.
CG 20 26 07 04 0 ISO Properties,Inc.,2004 Page 1 of 1
COMMERCIAL GENERAL LIABILITY
POLICY NUMBER: 3DS5450-M9O8894
Essex Insurance Company
THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED ENDORSEMENT—
PRIMARY AND NONCONTRIBUTORY
This endorsement modes insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE FORM
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE FORM
SCHEDULE
ADDITIONAL INSURED
P'E'RSON OR ENTITY:
City of El Segundo
Its Officers,Officials, Employees,
Agents and Volunteers
350 Main Street
El Segundo,CA 80245
Please refer to each coverage form to determine which terms are defined.Words shown in quotations on this
endorsement may or may not be defined in all coverage forms.
SECTION 11—WHO IS AN INSURED is amended to include as an Additional Insured the person(s)or entity(s)shown
in the Schedule above, but only as respects negligent acts or omissions of the Named Insured and only for
"occurrences","claims"or coverage not otherwise excluded by this insurance.
Where no coverage applies to the Named Insured, no coverage or defense applies to the Additional Insured shown in
the Schedule above.
No coverage applies to the Additional Insured scheduled above for any"bodily injury", "personal and advertising
Injury", or"property damage"to any"employee`of the Named Insured or to any obligation of the Additional Insured to
indemnify another because of damages arising out of such injury.
Subject to the above,when coverage appl'ie's to the Additional Insured(s)listed above„it shall be primary insurance as
respects any"claim", loss,or liability arising out of the Named Insured"s operations as covered by this Insurance. If
coverage applies under this policy, any other Insurance maintained by the Additional Insured(s)as a Named Insured
shall be excess and non-contributory to the coverage provided by this Insurance.
All other terms and conditions remain unchanged.
MEGL 0010 0311 Includes copyrighted material of Insurance Services Office, Inc.
with Its permission.
Jan 19 16 12:21 p Zebra Entertainment&Ev 8183047558 p.4
0 AlIF IM
A"A-4ALAVAL M& JEL
January 19, 2016
City of El Segundo-Recreation and Parks
Monse Palacios
401 Sheldon Street
El Segundo,CA 90245
Regarding:All Event Dates-2016
Dear Ms. Palecios,
This confirms that Zebra Entertainment and Events does not own or rent any vehicles, and
therefore does not carry any Automobile Liability Insurance. We cannot cover vehicles privately
owned by Independent Contractors. Our Insurance carrier does not offer coverage for hired
and non owned vehicles for our class of business.
The operators we contract with are all Independent Contractors, and not employees, so
therefore we are not required to carry any Worker's Compensation policy for them, according to
the Califomis Labor Code.
Thank You,
Shelly Mazer, owner
Zebra Entertainment and Events
11024 Balboa BIPA SWM 118 Grana kM11A CalVornla 91344 818.368.1818 wvnxZ ebrafterfalnmnbindEvents,con
May 261611:17a Zebra Entertainment&Ev 8183047558 p.4
CITY OF EL SEGUNDO
WORKERS' COMPENSATION DECLARATION
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE
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 PROVIDED
FOR IN LABOR CODE § 3706, INTEREST, AND ATTORNEY'S FEES.
I affirm under penalty of perjury under the taws 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_
Policy No.
(�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:
Carrier Policy Number Expiration Date .
Name of Agent Phone#
{ ff I certify that, in the performance of the work set forth In the agreement with the City of El Segundo,J will not
employ any person in any manner so as to become subject to the workers' compensation laws of California, and
agree that, if I should become subject to the workers' compensation provisions of Labor Code § 3700 1 must
Immediately comply with those prov ns or ttm re ent will automatically become void.
Signature of Applicant Date
Reviewed b , l
1