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PROOF OF INSURANCE (2017 - 2017) CLOSED 0 ATE AC" CERTIFICATE OF LIABILITY INSURANCE D06/08/2017Y) 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 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 N poCI PHONE -FAX Specialty :Mk• (A/C ,No): 401 Ed g ewater Place, Suite 400 ADDRESS. PRODUCtR Wakefield, MA 01880 COSTOMER VD : M SUREIR t S t AFFORDING COVERAGE NAIC# INSURED INSURERA: New Hampshire Insurance Company 23841 Disco Freaks INSURERB: United States Fire Insurance Company 21113 6502 Starshine Dr. INSURER C: Huntington Beach, CA 92647 INSURER D: 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. LTR TYPE OF INSURANCE AD ryry INSR WVO a POLICY NUMBER (MM/DD/YYYY) �POLICY EXP - ------ INSR DL S BR pttiLlcv Lr='� r;o M/DDIYYYYI LIMBS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X, COMMERCIAL GENERA LIABILITY 30 X SEL012342979 06/15/2017 07/26/2017 DAMAGE 10 FEW ED "` °° 0 CLAIMS-MADE I X„ OCCUR _.ME0 FIX?(Any one par,SQn). .,., $ 5,000__II X Host,Liquor PERSONAL&ADV INJURY $ 1,000,000 B X Medical Expense US759826 06/15/2017 07/26/2017 GENERAL AGGREGATE $ 2,000,000 II X 4 L AGGREGATE LIMIT APPLIES POECR: PRODUCTS-COMP/OPAGG $ 1,000, 000 III POLICY AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT °. (Ea accident) $ ANY AUTO ..,,,. ..... . BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per er accident) $ SCHEDULED AUTOS PROPERTY jAMA $ HIRED AUTOS (Per accident NON-OWNED AUTOS $ UMBRELLA LAB OCCUR EACH OCCURRENCE $ EXCESS LIAB I CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION VVCo+A-Tu- OI - ANY PROPRIE OR/ARBTN RYEX ECUTIVE Y� EL Ep H (,IICIDENT -FR OFFICER/MEMBER EXCLUDED? EACH ACCIDENT $ (Mandatory m 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 This coverage is with respect to Centennial Summer Concert Series event to be held 07123/2017-07/23/2017 at Library Park El Segundo CA 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 St. El Segundo, CA 90245 AUTHORIZED REPRESENTATIVE ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved, POLICY NUMBER: 12342979 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 St., El Segundo, CA, 9024 Name Of Person(s)Or Organization(s) (Additional Insured): City of El Segundo, its officers, officials, employees, agents, and volunteers, 350 Main St., El Segundo, CA, 9024 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 04 13 C Insurance Services Office, Inc., 2012 Page 1 of 1 POLICY NUMBER: 12342979 COMMERCIAL GENERAL LIABILITY CG 20 26 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL AL IINSU ECG - 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 State Farm Mutual Automobile Insurance Company H 900 Old River Road III" t IIIIIX i Bakersfield,CA 93311 �1u„' Y' P ., NIT c: I u AT2 009714 0009 A-8827 A 6502 STOARSHINE DR AUTO RENEWAL HUNTINGTN BCH CA 92647-2941 . PREMIUM PAID: $528.05 DO N0 I.t'AY. Your premium is billed through the State Farm Payment Plan State Farm Payment Plan Number, 1158073523 NO Your State Farm Agent FERRARO JR INS AGENCY INC Policy Number: 4391925-E31-75 Office:714-848-6368 Policy Period: May 31,2017 to November 30, 2017 Address: 17011 BEACH BLVD STE 826 Vehicle: HUNTINGTN BCH,CA 92647-5995 2005 CHEVROLET C2500 It you have anew ordtrent car,have added anydrbrers,orhave moved, Principal Driver: plbase contact youragent GRADY SHELTON When you provide a check as payment,you authorize us transfer,funds may be withdrawn from your account as soon either to use information from your check to make a as the same day we receive your payment, and you will not one-time electronic fund transfer from your account or to receive your check back from your financial institution, process the payment as a check transaction, When we use information from your check to make an electronic fund Policy Number:4391925-E31.75 Page number 1 of 4 Prepared April 25,2017 10045133 143562 201 11.12.2014 You uol�,ild lul,!lil 4V. luau UPII Q Know.� I(liipi .,py� � II. 'lllim Ilu U'tl M1vh.audiihw1„ry Your auto insurance premium is $528.05. no6HT 911 I;,, ”"Ilouuu�l 11 ull�' gill ., � 7 � Illllllu Did you know you may qualify for a discount. „I bl li tr Call State Farm"'Agent FERRARO JR INS AGENCY INC at u I L.. IIIU 714-848-6368 'Not all discounts are available in every state, and discount amounts may vary by state. 024811 "WN 1 �'�' w,.Nfi Will q m IIY1%1 A,t ll'n�111! Review your policy informatlon carefully.If anything is incorrect,or if there are any changes, please let us know right away, Vehicle Identification How is this vehicle normally used? Netlonal average:12,000 miles driven Vehicle Description Number(VIN) Who principally drives this vehicle? annually per vehlcle 2005 CHEVROLET C2500 1 GCHC23U85F967433 GRADY SHELTON,a married male,who To Work,School or Pleasure,Driven over will have 38 years of driving experience as 7,500 miles annually. of May 31,2017. Other Household Vehicle(s) Your premium may be influenced by other State Farm policies that currently insure the following vehicle(s) in your household; 2009 GMC YUKON With Drive Safe&Save TM, mileage information from your model. In addition,we review the comprehensive, collision, vehicle is used to determine your discount, Your calculated bodily injury and property damage claim experience annual mileage is 20,700. annually to determine which makes and models have Premium Adjustment earned decreases or increases from State Farm's standard Each year,we review our medical payments and personal rates. If any changes result from our reviews, adjustments injury protection coverages claim experience to determine are reflected in the rates shown on this renewal notice, the vehicle safety discount that is applied to each make and Assigned Driver(s) The following driver(s)are assigned to the vehicle(s)on this policy. Driving Experience as of Marital Name May 31,2017 Gender Status GRADY SHELTON 38 years Male Married Other Household Driver(s) In addition to the Principal Driver(s)and Assigned Driver(s), your premium may be influenced by the drivers shown below and other individuals permitted to drive your vehicle. This list does not extend or expand coverage beyond that contained in this automobile policy. The drivers listed below are the drivers reported to us that most frequently drive other vehicles in your household. CATHERINE SHELTON Principal Driver&Assigned Drivers Your premium may be influenced by the information shown For each automobile,the Principal Driver is the individual for these drivers. who most frequently drives it, Each driver is designated as an Assigned Driver on the household automobile that he or she most frequently drives. Policy Number:4391925-E31-75 Page number 2 of 4 Prepared April 25,2017 xiii �Vm w 4I „ AdNVA m r .. w P!L'^���ijtizitll�Y'xml;��'muiw'a,it iuuuV�pu ii'„ ° P COVERAGE INI”) i M411 S See your porrcy for an explanation of these coverages. A Liability Bodily Injury 250,000/500,000 Property Damage.Y 4 C -....,� Medical Payments 15,000 $$ �. .28 7.89 D 250 Deductible Comprehensive $35.20 N G 500 Deductible Collision $123.59 H Emergency Road Service $3.10 y B U Uninsured Motor Vehicle Bodily Injury 100,000/300,000 $38.78 U1 Uninsured Motor Vehicle Property Damage $221 Total Premium $528,05 If any coverage you carry is changed to give broader you the broader protection without issuing a new policy, protection with no additional premium charge,we will give starting on the date we adopt the broader protection. I IR SC W t R T S These adjustments have already been applied to your premium. Multiple Line _ ✓ Iticar ✓ Vehicle Safety "�..�"�".._.,-,��.�._.. � �� ✓ Driving Safety Record ✓ California Good Driver ✓ Loyalty Total Discounts $1,331,88 5L)IGt;OH I1,GE'S AN[) l[NS'Ci N.II '.IIr'' Driving Safety Record Rating Plan shall be lowered by 2 levels, The Rate Level is Increased If Your driving safety record,along with other rating factors, there are subsequent chargeable accidents or convictions. determines what you pay for Liability, Medical Payments, Definition of Chargeable Accidents Comprehensive,Collision, and Uninsured Motor Vehicle Chargeable accidents for new business are those which Coverages. Policyholders with no accidents and convictions resulted In bodily Injury or death or in payment(s) by an pay less than those with accidents and convictions. insurer due to damage to any property in the amount of The Driving Safety Record Rate Level that is assigned to more than$1000. For accidents occurring prior to your policy moves up,down,or stays the same every policy December 11,2011, an accident shall be chargeable renewal,depending upon your driving record. For every 12 provided it resulted in death or In payment(s)by an insurer months since the renewal following the occurrence of a due to damage to any property in the amount of more than chargeable accident or the conviction of a minor violation, $750. the initial assigned Driver Record Level for that chargeable For applicants without prior insurance at the time of the accident or conviction shall be lowered by 1 level, For each accident, an accident shall be chargeable provided it 12 month period since the conviction of a major violation, resulted in damage to any property in the amount of more the initial assigned Driver Record Level for that conviction (continued on next page) Policy Number;4391925-E31-75 Page number 3 of 4 Prepared April 25,2017 024812 '�'V�jvlj'i"�";d�N,dp4ilVlwi�"ag,����u uV'im �uv ww'dVi �WwNi �v � �� SIlLilRC'l°'MIMES AND [)I'm'COt.tt' F'S ntinil(':'d than$1000(more than$750 if the accident occurred prior to property damage liability coverage and collision coverage December 11,2011), combined. Chargeable accidents for renewal business are those which For more information about the rating plan, please contact resulted in bodily injury or death or State Farm claim your State Farm agent. payments totaling more than$1000(more than$750 for Superior Driver Rate Level accidents occurring prior to December 11,2011)under AI'.X)rrll lNAL,IIn' RORMA't"itu'mN If the above information is Incomplete or inaccurate,or if you want to confirm the information we have In our records please contact your agent, tm mportain'; mmtlwcmm IRet'ar Iii n,g Your IPIU°eirnitlmum State Farm works hard to offer you the best combination of price, service, and protection. The amount you pay for automobile insurance is determined by many factors including: • The coverage you have • Where you live • The kind of car you drive • How the car is used • Who drives the car Any premium adjustment is reflected on this Auto Renewal,If you have any questions,please contact your agent. BIIIIIIV' iIIIIigj 'a new q �.�� �III„gym�mllu pl um �mm �°m�i�'�'III'' mm�,'w'mN��i� When you buy an additional car or one that replaces a car already on your policy,you need to report the change to your agent aromotly. Even though the dealership you purchased the car from may offer to notify your agent or insurance company,you,as the named insured, are responsible for reporting all changes to your auto policy. By contacting your agent,you can help: • avoid any complications or lack of coverage in the event of an accident or loss, • avoid insurance verification problems with a lienholder, the police,or the department of motor vehicles, and • ensure that you receive any new discounts you may be entitled to, Your current State Farm policy automatically provides certain coverages for a new or replacement car for up to a specified, limited number of days after you take possession of the car. Please refer to your policy for the number of days that applies in your state. If you have any questions about coverage for a newly acquired oar, please contact your State Farm agent. Disclaimer., This message is provided fir informational purposes only and does not grant any insurance coverage, The terms and condrflons of coverage are set forth in your State Farm Car Policy booklet, the most recently Issued Declarations Page,and any applicable endorsements. Policy Number:4391925-E31.75 Page number 4 of 4 Prepared April 25,2017 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. L_)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# . 5 1 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 become subject to the workers' compensation provisions of Labor Code § 3700 1 must immediately comply with;the provisions o will automatically become void. Signature of Applicant Date Agreement for. Dated . ... .... ..... ...... Reviewed h 1