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PROOF OF INSURANCE (2018) CLOSED 1 CERTIFICATE OF LIABILITY INSURANCE I DATE 4/27/017 II 4/27/2017 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 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 endorsement(s). PRODUCER CONTACT Stephanie Weiss Specialty Insurance Agency PHONE 715-246-8908 FAX 715-246-4257 Performers of the U.S. (AIC�No.Ext); ( c,No): . P.O.Box 24 ADARESS: certs @specialtyinsuranceagency.com .. ..., ... ... .,... New Richmond,WI 54017 INSURER(S)AFFORDING COVERAGE NAIC INSURER # .,,.., „P A: Evanston Insurance Company 35378 INSURED eter A. Ellison INSURER B dba One World Rhythm 1317 N San Fernando Blvd#512 INSURER D Burbank,CA 91504 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. INSR TYPE OF INSURANCE ADDLSUBR POLICY EFF POLICY EXP LIMITS LTR I POLICY NUMBER (MM/DD/YYYY1....(MMIDD(YYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 3,000,000 CLAIMS-MADE 1X_1 OCCUR IPRFMI(YET_0TFENcTEbnrel $ 300,000 MED E X P(Any one person) $ 5,000 A X X 2CN0156-4517 05/25/2017 05/24/2018 PERSONAL&ADV INJURY $ 3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 5,000,000 X POLICY ECT I LOC PRODUCTS-COMP/OP AGG $ 5,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ „(Ea atrc(rwnt) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED TYI AUTOS ONLY AUTOS ONLY (Pert I(OunDAMAGE $ UMBRELLA LIAB w OCCUR TE $E $ EXCESS LIAB II EACH OCAURRENC VV4 CLAIMS-MADE AGGREGATE DED I I RETENTION$ $ WORKERS PER AND EMPLOYE RS'L ABILIITY YIN �,STATUTE ,12 E0 ,H,,,,,,,.. (Maodaory MNH)EXCLUDED?ECUTIVE ❑ NIA E,L,D SEASECEA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ A BUSINESS PERSONAL PROPERTY- 2CN0156-4517 05/25/2017 05/24/2018 AGGREGATE $ 10,000 INLAND MARINE DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) PERFORMER IS A NAMED INSURED AS A MEMBER OF PERFORMERS OF THE U.S.: Peter A.Ellison dba One World Rhythm Additional Insured:The City of El Segundo,its officers,officials,employees,agents and certified volunteers Event Dates:2017-06-15 CERTIFICATE HOLDER CANCELLATION City of El Segundo Public Library 111 West Mariposa Avenue SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE El Segundo,CA 90245 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE (� ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD COMMERCIAL GENERAL LIABILITY gig POLICY NUMBER: 2CN0156-4517 M KEG EVANSTON INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED This endorsement modifies insurance provided under the following COMMERCIAL GENERAL LIABILITY COVERAGE FORM " PRODUCTS/COMPLETED OPERATIONS COVERAGE FORM LIQUOR LIABILITY COVERAGE FORM PROFESSIONAL LIABILITY COVERAGE FORM Please refer to each coverage form to determine which terms are defined. Words shown in quotations on this endorse- ment may or may not be defined in all coverage forms. SCHEDULE Person or Entity: Any person or organization to whom you are obligated by valid written contract to provide such coverage. Additional Premium: $ (Check box if fully earned.®) Included WHO IS AN INSURED is amended to include the person or entity shown in the Schedule above as an Additional Insured under this insurance, but only as respects negligent acts or omissions of the Named Insured and only as respects any coverage not otherwise excluded in the policy. Our agreement to accept an Additional Insured provision in a contract is not an acceptance of any other provisions of the contract or the contract in total. When coverage does not apply for the Named Insured, no coverage or defense shall be afforded to the Additional In- sured. No coverage shall be afforded to the Additional Insured for injury or damage of any type 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 or damage. All other terms and conditions remain unchanged. MEGL 0009-01 0411 Includes copyrighted material of Insurance Services Office, Inc. Page 1 of 1 with its permission. COMMERCIAL GENERAL LIABILITY POLICY NUMBER: 2CN0156-4517 IRIKE " EVANSTON INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET WAIVER OF SUBROGATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM SCHEDULE Additional Premium: $ 0 Name of Person or Organization: Any person(s)or organization(s)to whom the Named Insured agrees to waive rights of recovery in a written contract. The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV — COMMERCIAL GENERAL LIABILITY CONDITIONS) is amended by the addition of the following: We waive any right of recovery we may have against the person or organization shown in the Schedule above as respects written contracts that exist between you and such person or entity, provided you have agreed in writing to furnish this waiver. This waiver applies only to the person or organization shown in the Schedule above. All other terms and conditions remain unchanged. MEGL 0241-01 04 11 Includes copyrighted material of Insurance Services Office, Inc.with its Page 1 of 1 permission. POLICY NUMBER: 2CN0156-4517 COMMERCIAL GENERAL LIABILITY CG 20 01 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY Y AIND NONCONTRIBUTORY - OTHER INSURANCE CONDITION 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 (2) You have agreed in writing in a contract or Condition and supersedes any provision to the agreement that this insurance would be contrary: primary and would not seek contribution Primary And Noncontributory Insurance from any other insurance available to the additional insured. This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: (1) The additional insured is a Named Insured under such other insurance; and CG 20 01 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1 mm IMPORTANT-IDENTIFICATION CARDS STATE FARM 5. tateFar tateFar'm CALIFORNIA THIS CARD Ml%T BE KEPT IN THE INSURED UR070R INSURANCE CARD VEHICLE FOR PRODUCTION UPON DEMAND State Nrm Mutual Automobile N8URE D E �1 PETER CA 9 9501 I.,. g wr.; Ry IF YOU HAVE AN ACCIDENT•NOTIFY THE POLICE IMMEDIATELY 1 ^"rsr' t rtivt a b7 rdu rn� u�i I lilt lrr r��^v inl� to r AAUTL Y *mv V Xn,<+ uru„i7pmp i 1v VOL p.,mm,,urya, 2 D, n,j YvrI,i rti4:'�I”; , t.v�V`;w,'.a RI' ,iY%'�'f l;,i r'ryt7!I PR t',;u°S 11a-P.,x,I.'X'.7d I �„UR r' �'rr n'�rI Yo .I r I�,i ^r,r,) �,,11,r it r �& in POLICY NUIMBER m6700•A055.75 EFFECTIVE A.,kO Irar POUCw"a:YCO,U900JS CAPER).1LY, W5 VAI`O04`S1eJr r'R 2016 w PIAKE FORD JAN052017 TO JUL052017 CONS7►ME ANY PARrOF YOUR IN J POLICY. A,3r-,'N- 610 IV if 5'7O c al ra ni I' See policy for full name and Vehicle e i VIN NOLS7EX3G72611 How to Iden our coven UT I pr"Y' TNNpplq UG14J AU 3197.894 rd I^n V"ruDU'n'WO A.l;.q"F7'rA"'w�°N Cf Vtl lif4 4P Lb9 fi CuIMsX. '''I Scr.tcc U 'N, r d P'� Y THE V''C91i..U4,hI MR�ILT'�'Y'4IE Po1UPWMUIVp V.0 LUIY U.1V4'UT�1 on y S IkaYh,Ihsnrcn�� UI �"r ���ed",' �r Jehuir.PD P'Rfe' �,. °I''q,'II,"f a I �Ir.ncnt RiCi I i i� a•.rel Frpencrs r I 'f�r'r r Ix;nro.rYr ancY KEEP A CARD IN YOUR CAR THIS CARD IS INVALID IF THE POLICY FOR WHICH IT WAS ISSUED LAPSES OR IS TERMINATED. KEEP YOUR CURRENT CARD UNTIL THE EFFECTIVE DATE , � CARD. E COPY OF S FO SHOULD BE FRED IN THE V CLE AT ALL TIM THE FO NEEDED OF INSURANCE IN COURT. SUBMIT E OF A I� Y00dPY OF A �rTH'YCUt VEHICLE GISTI 110f F r . A IdI r p raaWL��for 6rrerrwy afiraa�^mid kRw A. w �o runririm Cwd DRIVER 11-110 I�u'L?wW,', hL ., .r END IE gr, l,'Iy.➢'u','Id`I"rn li'PiI PA, ELLISON m f R I PETER ANTHONY iYla"'r'lllr;"" 12401 FILMORE ST SPC 737 oI SYLMAR,CA 91342 11f1d�"�I�h�ill I IC.i GN ii,V°.9^'^bd"'Irr4'd'"d illl° n.. CORR R..CNS 1961 SEX M !y !^' u::�r� IR:IAINU HGT q46" ;d �l UN'fi liar f1LY pmif7212ntl'I604Y� Y39'I 'PI'lk'1�I.R�RSI1Yd 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: (__) l 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. .... _., .._..r__.... ... .,, -, 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 — m Policy Number Expiration Date _,.�.... ... ........ .. ...... _,. _.. Name of Agent _.m...................... ...N,_.. ..... Phone# ..............._.... _ ...._ ------ r L I certify that, in the performance of the work set forth in the agreement with the City of El Segundo, I will not e�riploy any person in any manner so as to become subject to the workers' compensation laws of California, and agree that, if I should becoe,subjecl to the workers' compensation provisions of Labor Code § 3700 1 must immediately comply with�h 6 e provisions or the agreement will automatically become void, .: um Signature of Applicant b. __� ..._ Date - ti Agreement for: ... Dated, Reviewed by: 1