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PROOF OF INSURANCE (2017) CLOSED ACi" ;�LO DATE(MMIDDnYYY) �M. �IRKErr° CERTIFICATE OF LIABILITY INSURANCE I 616/2017 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 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 _N M.: Stephanie anie Weiss Specialty Insurance Agency PHONE FAX Performers of the U.S. ..� .tt 715-246-8908 1. 715-246-4257 P.O.Box 24 AEts: certs@specialtyinsuranceagency.com New Richmond,WI 54017 INSURERIS)AFFORDING COVERAGE NAICA INSURER A: Evanston Insurance Company 35378 INSURED Lisa A.Stanley INSURER B: dba The Voices of Christmas,The Wonderelles, Make Mine Acoustic,WE-VOC Entertainment INSURER C: 5033 Denny Avenue INSURER D North Hollywood,CA 91601 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. roNSR IibuL SUBR 06LICY EFF POLICY EXP' TPEOFINSURNCE YNUMBER MMDYYYY1J,NMDDrYY7 LTR UL- C LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE s 3.000,000 CLAIMS-MADE a OCCUR i UG IUHhNroLO C PREM'RSES'(Ea ac:raarreeridsl �5 300,000 MED EXP(Any one peraon) $ 5.000 A X X 2CN0141-7294 08102/2016 08101/2017 PERSONAL BADVINJURY $ 3,000,000 GEN%AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 5,000,000 X POLICY PRO- JECT F-�LOC PRODUCTS-COMPIOPAGG $ 5,000,000 OTHER; Is AUTOMOBILE LIABILITY COMDINED SINGLE LIMIT $ PEs.Wdentl ANY AUTO BODILY INJURY(Per person) Is OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident)�S HIRED NON-OWNED AMAGE $ ® AUTOS ONLY AUTOS ONLY (Par Kddontl - Ns UMBRELLA LIAR OCCUR EACH OCCURRENCE Is EXCEpSSLIpAR CLAIMS-MADE' AGGREGATE S DEO II III RETENTION S V S WOkERSCOMPENSATION E.L. PER N 00�I AND EMPLOYERS'LIABILITY I 1 ANYPROPRIEYOWPARTNERIEXECUTIVE YIN EACH ACCIDENT Is s OFFYCERIMEN4'SCR EXCLUE It andalory In NH) E.L.DISEASE-EA EMPLOYE $ NI++poa describe under DESLt RIP Tro0'N OF OPERATIONS„belowwr E.L.DISE ASE-POLICY LIMB $ BUSINESS PERSONAL PROPERTY- A INLAND MARINE AGGREGATE S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Addi cnel Remarks Schedule,may be attached I more epee*to mqulred) PERFORMER IS A NAMED INSURED AS A MEMBER OF PERFORMERS OF THE U.S.: Lisa A.Stanley dba The Voices of Christmas,The Wonderelles,Make Mine Acoustic,WE-VOC Entertainment Additional Insured:The City of El Segundo,its officers,officials,employees,agents and volunteers. Email:SGreen@elsegundo.org Attn:Shawn Green Event Date:June 18,2017 CERTIFICA'T'E HOLDER CANCELLATION El Segundo Recreation and Parks 101 W.Mariposa Ave. 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. AUTHORMED REPRESENTATIVE 0 1968.2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 2CN0141-7294 COMMERCIAL GENERAL LIABILITY CG 20 12 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - STATE GOVERNMENTAL AGENCY OR SUBDIVISION OR POLITICAL. SUBDIVISION I - PERMITS OR AUTHORIZATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE State Or Governmental Agency Or Subdivision Or Political Subdivision: City of El Segundo City Clerk Attn: Recreation & Parks Director 350 Main Street, Room 5 El Segundo, CA 90245-3813 The City of El Segundo, its officers, officials, employees, agents and certified. 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. This insurance does not apply to: include as an additional insured any state or a. 'Bodily injury", "property damage" or governmental agency or subdivision or political "personal and advertising injury" arising out subdivision shown in the Schedule, subject to the of operations performed for the federal following provisions: government, state or municipality; or 1. This insurance applies only with respect to b. 'Bodily injury" or "property damage" operations performed by you or on your behalf included within the "products-completed for which the state or governmental agency or operations hazard". subdivision or political subdivision has issued a permit or authorization. B. With respect to the insurance afforded to these However: additional insureds, the following is added to Section III—Limits Of Insurance: a. The insurance afforded to such additional If coverage provided to the additional insured is insured only applies to the extent permitted required by a contract or agreement, the most we by law; and will pay on behalf of the additional insured is the b. If coverage provided to the additional amount of insurance: insured is required by a contract or 1. Required by the contract or agreement; or agreement, the insurance afforded to such additional insured will not be broader than 2. Available under the applicable Limits of that which you are required by the contract Insurance shown in the Declarations; or agreement to provide for such additional whichever is less. insured. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. CG 2012 0413 0 Insurance Services Office, Inc.,2012 Page 1 of 1 POLICY NUMBER: 2CN0141-7294 COMMERCIAL GENERAL LIABILITY CG 20 0104 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONC NTRIBUT''O Y - 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 This insurance is primary to and will not seek additional insured. 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 0104 13 0 Insurance Services Office, Inc.,2012 Page 1 of 1 California'Evidence of Liability Insurance Here are your Evidence of Liability Insurance Cards. %= . 1-800-841-3000 Two cards have been provided for each vehicle insured. One carts must be carried in the proper GEICO GENERAL INSURANCE CdMPAOY, Insured vehicle. Proof of insurance is required to P.O. Box 509090- San Diego, CA 92-1,50-9,090 register or renew the registration of your vehicle. A NAIC Code: 35882 law enforcement officer can ask you to prove that Policy Number Effective Date Expiration Date you have liability insurance meeting the basic 4416-79-30-34 05-16-17 : 11-16-17 requirements of California law. Year Make Model Vehicle ID No. 2000 CHEV EXP G2500-, 1 GCFG25M9Y1238013 A violation of these requirements can result in a fine Insured: of up to: Neal E Himelhoch $1,000 for the first time Lisa A Stanley $2,000 for additional times 5033 Denny Ave Also, a judge can have your vehicle impounded. N Hollywood CA 91601-4026 False proof of insurance may result in a fine up to $750 and 30 days in prison. The coverspe provided by Ihls poNloy meets the minimum requirements of seeuons 16056&I WW,5 of the CalUomie Vehicle Code,minimum Ilelslllly NNmiNa prrasraribed by law- Due to space limitations on the ID card, only the Named Insured and the Co-insured are listed. For a full list of drivers covered under this policy, please reference the Drivers section of your Declarations Page (Page 13). NEAL E HIMELHOCH AND LISA A If you would like additional ID cards you can go STANLEY online to geico.com or call us at 1-800-841-3000. 5033 DENNY AVE N HOLLYWOOD CA 91601-4026 a California Evidence of Liability Insurance 9810C.csfW m 1-800-841.3000 GEICO GENERAL INSURANCE COMPANY P,O, Box 609090- San Diego, CA 921'50"'8090 NAIC Code: 35882 Policy Number Effective Date Expiration Date 4416-79-30-34 05-16-.17 11-16-17 Year Make Model Vehicle ID No. 2000 CHEV EXP G2500J ' 1GCFG25M9Y4238013 Insured: Neal E Himelhoch Lisa A Stanley 5033 Denny Ave N Hollywood CA 91601-4026 q The oowrape pWWrA by this�Wye CAet mlmmi m NNmN slits ecm6 0 u e 10036 61OM 5 of the Caftmis y law. PIRS>1�N19 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 Y 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# (__)V 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 subjec o the workers' compensation provisions of Labor Code § 3700 M must immediately comply with tho provislo o t agree ent will automatically become void. Signature of Applicant �� Date � . Agreement for: ,� 11?11('A�( . � ,� H Dated: Reviewed by: 0, 1