PROOF OF INSURANCE (2017) CLOSED (2) .�IIC'Rrs CERTIFICATE OF LIABILITY INSURANCE DATEiMMIDDrrvrY)
� 1 03111312017
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. j
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or 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 endomement(s).
PRODUCER CONTACT
yAM Sam Muradyan
Liberty United Insurance Services,Inc. ;P1I,ONE 11 FAX
IM,U.Eatit* (888)6863768 INC N¢I.i888)2ti x•668'9
6005 Vineland Avenue,Suite 203 E-MAIL
North CA 91606 �_' Sam@libertyunitedinsuraiiice.com
License Hollywood,ll wood,1 INSURERi,S)AFFORDING COVERAGE NAIL/
INSURER A: United States l=ire Insurance Co
INSURED INSURER 8:
Elite Special Events,Inc INSURER C.
11278 Los Alamitos Boulevard#101 INSURER D:
Los Alamitos,CA 90720 N INSURER E:
N INSURER F;
COVERAGES CERTIFICATE NUMBER: 00000000-279009 REVISION NUMBER: 103
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.
.... ... .... .
LTR VNSR ADDL'SUDiR' POLICY 9F-F- PO Y
TYPE OF INSURANCE LIMITS
A Y N SRPGP-101-0716 10128/2016 10/28/2017 EACHOCCURREME $ 1000,000~
. . i rn IMMIODIYYYYI IMMIDDTYYKYR
COMMERCIAL GENERAL LIABILITY
°LRATi-0 lED �.
CLAIMS-MADE
5-171 OCCUR P (.q-d iMSIMMMY S 300,000
,PERSONAL,IU,ADV ......_.........-.aQQO,zp. Q,...
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
OT VIER.❑jECo- ❑LOC I PRODUCTS-COMP/OPAGG s_ 2,,000,000....
AUTOMOBILE LIABILITY II1Oui5VNGLE LIMIT 5
ANY AUTO BODILY INJURY(Perperson) S
OWNED SCHEDULED BODILY INJURY(Per 5
AUTOS ONLY AUTOS
HIRED NON-ONMED PRdPERTY DAMAGE S
AUTOS ONLY AUTOS ONLY lPor-',oc:dderw'W
S
UMBRELLA LIAR OCCUR EACH OCCURRENCE $
EXCESS LIAB w .�,CLAIMS-MADE I AGGREGATE S
DED RETENTIONS C $
WORKERS COMPENSATION I STATUTE N N ERH.
AND EMPLOYERS'LIABILITY YIN
ANY PROPRIETOMPARTNER110 ECUTIVE El N NIA
EL EACH ACCIDENT $
OFFICER/MEMBER E.XCLUDED7' .
IMandak"In NH) E.L DISEASE-EA EMPLOYEE„$
"Kyuus•describe ceder .s
DESCRLPT'I�ON OF OPERATIONS below EL DISEASE-POLICY LIMIT -
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be atle¢Md K more space is required)
City of El Segundo,its officers,officials,employees and volunteers are listed as additional insureds ,fir
Event Date:May 6th,2017
Scheduled activities exclusion endorsement applies:Mechanical Bull,Mechanical Surfboard,Zip Line,&Permanent Rock
Wall Structure
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
City of El Segundo ACCORDANCE WITH THE POLICY PROVISIONS.
350 Main Street
El Segundo,CA 90246 AUTHORIZED REPRESENT n
(SMS)
m 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 26(2016103) The ACORD name and logo are registered marks of ACORD
Printed by SMS on March 13,2M7 at 01:24PM
COMMERCIAL GENERAL LIABILITY
CG 20 26 07 04
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - DESIGNATED PERSON SOIN OR
ORGANIZATION
Policy Number. SRPGP-101-0716
Insured: Elite Special Events, Inc
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART "
SCHEDULE
Name Of Additional Insured Person(s) Or Organization(s)
The City of EI Segundo,its officers,officials,employees,agents and volunteers
350 Main St
El Segundo,CA 90245
V
Information required to complete this Schedule, if not shown above will be shown in the Declarations.
Section II -WHO IS AN INSURED is amended to
include as an insured the person(s)or organization(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 of the acts or omissions 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
�L.,Y►I °a .�° .......,. ..,„ DATE(MM=ft-YYY)
C40 CERTIFICATE OF LIABILITY INSURANCE 3/13/2017
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(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
McAnany Insurance Services, Inc. ONES.T....D.a(805)3=�'.......0 0A)"''...........
14165 MANa.EXti 79-8801 �.Wcd.o!..�.e.°.5.x..2.°.°..°.5.01.......................
E. Thousand Oaks Blvd atu3
_ RE_9'S:
Suite 325 INSURER(S)AFFORDING COVERAG.E..........................................................................NAIC p.............
Westlake Village CA 91362 INSURERA:Callfornia Auto Insurance 38342
INSURED INSURER B:
...............................................................................
ELITE SPECIAL EVENTS, Inc. INSURER C:
404 N Sparks St INSURER D:
.................
INSURER E
Burbank CA 91506-1963 C INSURER F:
COVERAGES CERTIFICATE NUMBER:CL1691303478 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.
I�...LTR TYPE OF INSURANCE iWW'�� ... POLICY NUMBER (MNOVDDYYYYI l woos Y'�"1 .... LIMITS.... .... ....
..,
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S
CLAIMS-MADE OCCUR PREMPa�.S ti7 e ..................E........... ......................
MED EXP(Any one person) S
PERSONAL&ADV..INJURY............."'.....................................................................
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $
POLICY I JEC1 r
AUTOMOBILE LIABILITY L�, COMBINED SINGLE IMl'fGG $
1,000,000
.
.......... AI5 iden9 .... .................
% ANY AUTO BODILY INJURY(Per person) $
_
A ALL OWNED SCHEDULED
AUTOS AUTOS 13A040000023533 8/31/2016 8/31/2017 BODILY INJURY(Per accident) $
_.__.._.._..________
NON-OWNED PROPERTY DAMAGE $
HIRED AUTOS AUTOS (P..eragddenll ........
Theft Prevention Authority $
UMBRELLA UAB OCCUR EACH OCCURRENCE $
CLAIMS-MADE ............... —
EXCESS LIAR AGGREGATE $
D E D � V RETFNTIPNS $
WORKERS COMPENSATION PER I II OTH-
AND EMPLOYERS'UABILITY I$TAT,(JTg„l------L ER__,YIN
OFFICER/MEMBER EXCLUDED? �AECIEDAEN ,3
ANY PROPRIEfORIPARTNEWEXECUTIVE
In NH NIA
A E L....DIS............S...........-.................... ...... ...
(Mandatory ► ...................., ..,..,...... .EMPLOYEE $-- ---
ffy�B deyu be under -
DE'S�RIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT E
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required)
Certificate Holder and City of El Segundo, its officers, officials, employees, agents, and volunteers.
CERTIFICATE 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
350 Main Street ACCORDANCE WITH THE POLICY PROVISIONS.
El Segundo, CA 90245
AUTHORIZED REPRESENTATIVE
1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
IN8025(201401)
POLICY NUMBER: BA040000023533 COMMERCIAL AUTO
CA 20 48 02 99
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
DESIGNATED INSURED
RED
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
GARAGE COVERAGE FORM
MOTOR CARRIER COVERAGE FORM
TRUCKERS COVERAGE FORM
With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless
modified by this endorsement.
This endorsement identifies person(s) or organization(s) who are "insureds" under the Who Is An Insured Provi-
sion of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form.
This endorsement changes the policy effective on the inception date of the policy unless another date is indi-
cated below.
Endorsement Effective: 8/31/2016 Countersigned By:
Named Insured:
Elite Special Events,Inc. (Authorized Representative
SCHEDULE
Name of Person(s)or Organization(s): As noted on certificate of insurance.
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations
as applicable to the endorsement.)
Each person or organization shown in the Schedule is an "insured"for Liability Coverage, but only to the extent
that person or organization qualifies as an "insured" under the Who Is An Insured Provision contained
in Section II of the Coverage Form.
CA 20 48 02 99 Copyright, Insurance Services Office, Inc., 1998 Page 1 of 1 O
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 laws of California one of the following declarations:
U 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.
C_)I have and will maintain workers'compensation insurance as required by Labor Code§3700 forthe 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#
W I certify that, in the performance of the work set forth in the agreement with the City of El Segundo, I 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 provisions or the agreement will automatically become void.
Signature of Applicant Date -r—I Y-/7
Agreement for
Dated:
Reviewed by: .
1