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PROOF OF INSURANCE (2017) CLOSED DATE / 1m ' " CERTIFICATE OF LIABILITY I SURA CE 04/255207 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 Molder Is an ADDITIONAL INSURED,the polic,y(les)must be endorsed. It 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: HCC Specialty ONE fAX............. 401 Edgewater Place, Suite 400 ADPDDRs:c��ESI#I tIt�ISUCiI:R._.�................... Wakefield, MA 01880 cuTawull .o. = INSURER(S)AFFORDING COVERAGE NAIL#t INSURED INSURERA: New Hampshire Insurance Company 23841 Main Street Band INSURERB: United States Fire Insurance Company 21113 406 Maryland St. INSURERC: El Segundo, CA 90245 INSURERD: INSURER E: I .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. INSR AODL SUBA POLTCY-OF Poubfk0_._...... LTR TYPEOFINSURANCE I, R WYO POLICYNUMBER (MM/DD/YYYY) (MWDD/YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X SEL012341705 04/26/2017 07/07/2017 DAMAG' TO'AFNTE X COMMERCIAL GENERAL LIABILITY .PR MI ( .�_tarmncel $ 300,000 ryOCCUR 5,000 CLAIMS-MADE �X B M.4m4..taXP..(ARJ�,.4�g.9.S�A�.�.n).............$ X Host Liquor PERSONAL&ADV INJURY $ 1,000,000 ....................................................................................... B 1 X Medical Expense US758041 04/26/2017 07/07/2017 GENERAL AGGREGATE $ 2,000,000 POLICY I� 1,000,000 : X N 1 L AGGREGATEJLIMMIIT APPLIES L E . PRODUCTS-COMP/OP AGG $ PRO- AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ -- (Ea accident) — ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE $ HIRED AUTOS (Per accident) NON-OWNED AUTOS $ $ UMBRELLA LIAB EACH OCCURRENCE $ EXCESS LIAB CLAIMS MAD E AGGREGATE $ DEDUCTIBLE $ RETENTION $ WO'KERS COMPENSATION AND EMPLOYERS'LIABILITY YIN I ENT......`... ......$..................................................................... ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L,DISEASE-EA EMPLOYEE $ If yes,describe under " """' DESCRIPTION OF OPERATIONS below E L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) The Certificate Holder is added as Additional Insured with respects to our Insured's operations only This insurance is primary and non-contributory as required by written contract List of events covered under the above policy numbers can be viewed on page#2 of the certificate of insurance form CERTIFICATE HOLDER CANCELLATION City of El Segundo, Its officers, officials,employees, agents, and SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED volunteers IN ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street El Segundo, CA 90245 AUTHORREDREPRESENTATI'V& i mow. ACORD 25(2010105) ®1988-2010 ACORD CORPORATION. All rights reserved. POLICY NUMBER: 12341705 COMMERCIAL GENERAL LIABILITY CG 20 26 0413 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): As submitted to company and required by written contract. Information required to complete this Schedule, 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 additional insureds, the following is added to organization(s) shown in the Schedule, but only Section III—Limits Of Insurance: with respect to liability for "bodily injury", "property If coverage provided to the additional insured is damage" or "personal and advertising injury' required by a contract or agreement, the most we caused, in whole or in part, by your acts or will pay on behalf of the additional insured is the omissions or the acts or omissions of those acting amount of insurance: on your behalf: 1. Required by the contract or agreement; or 1. In the performance of your ongoing operations; or 2. Available under the applicable Limits of 2. In connection with your premises owned by or Insurance shown in the Declarations; rented to you. whichever is less. However: This endorsement shall not increase the 1. The insurance afforded to such additional applicable Limits of Insurance shown in the insured only applies to the extent permitted by Declarations. law; and 2. If coverage provided to the additional insured is 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 26 04 13 ©Insurance Services Office, Inc., 2012 Page 1 of 1 POLICY NUMBER: 12341705 COMMERCIAL GENERAL LIABILITY CG 20 11 0413 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 Designation Of Premises (Part Leased To You): City of El Segundo, its officers, officials, employees, agents, and volunteers, 350 Main Street, El Segundo, CA, 9 Name Of Person(s)Or Organization(s) (Additional Insured): City of El Segundo, its officers, officials, employees, agents, and volunteers, 350 Main Street, El Segundo, CA, 90 Additional Premium: Included Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to 2. If coverage provided to the additional insured include as an additional insured the person(s) or is required by a contract or agreement, the organization(s) shown in the Schedule, but only insurance afforded to such additional insured with respect to liability arising out of the will not be broader than that which you are ownership, maintenance or use of that part of the required by the contract or agreement to premises leased to you and shown in the provide for such additional insured. Schedule and subject to the following additional B. With respect to the insurance afforded to these exclusions: additional insureds, the following is added to This insurance does not apply to: Section III —Limits Of Insurance: 1. Any 'occurrence" which takes place after you If coverage provided to the additional insured is cease to be a tenant in that premises. required by a contract or agreement, the most we 2. Structural alterations, new construction or will pay on behalf of the additional insured is the demolition operations performed by or on amount of insurance: behalf of the person(s) or organization(s) 1. Required by the contract or agreement; or shown in the Schedule. 2. Available under the applicable Limits of However: Insurance shown in the Declarations; 1. The insurance afforded to such additional whichever is less. insured only applies to the extent permitted This endorsement shall not increase the by law; and applicable Limits of Insurance shown in the Declarations. CG 20 11 0413 © Insurance Services Office, Inc., 2012 Page 1 of 1 Page 2 of Certificate of Liability Insurance Date: 04/25/2017 Policy Numbers: SEL012341705 US758041 1) This coverage is with respect to Hometown Fair event to be held 05/06/2017-05/06/2017 at Library Park El Segundo CA 2) This coverage is with respect to City of El Segundo 4th of July Celebration event to be held 07/04/2017-07/04/2017 at Recreation Pai Main Street Vintage Band) Date: 411-17 To: City of El Segundo Re: Business Automobile Liability Insurance and Worker's Comp I,Jean-Louis Boudreau,band member of Main Street Band, certify that all band members are independent contractors. The band is not incorporated and does not cant'Business Automobile Liability Insurance. Thank you, .C Louis Boudreau 406 Maryland Street * Ell Segundo - CA 90245 * tel: 310.720.9360 * fax: 310.726.0138 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: P (_) 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. b (_)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# u. I certify that, in the performance of the work set forth in the agreement with the City of El Segundo, I will not ploy any person in any manner so as to become subject to the workers' compensation laws of California, and agree that, if I should beco subj t to the workers' compensation provisions of Labor Code § 3700 1 must immediately comply'wit 0 provisi ns or the agreement will automatically become void. Signature of Applicant Date 4 1 ct Agreement for..� Dated: Reviewed by 6�o w 1