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PROOF OF INSURANCE (2017) CLOSED C" CERTIFICATE OF LIABILITY INSURANCE I DATE 06/08/2017 Y) 06/08/2017Y) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS II 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 4:LYMENq'AC'1 NA : HCC Specialty rCd fig.past): Ica x No),. 401 Edgewater Place, Suite 400 ADDRE � .. . .. . Wakefield, MA 01880 COST914119I,.:.. INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: New Hampshire Insurance Company 23841 Aquarius 'INSURER B : United States Fire Insurance Company 21113 17738-4 Devonshire St. INSURER r Northridge, CA 91325 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. INSR TYPEOFINSURANCE A00L SUBRI POY POLICY' X LTR INSR WVD POLICYNUMBER ( 1DD YVV) DJMY YD LIMITS EACH OCCURRENCE $ 1,000,000 A GENERAL LIABILITY X SEL012342859 06/09/2017 07/12/2017 DAMAGE? RENTED 300,000 X COMMERCIAL GENERAL LIABILITY PREMI,SFS.((r;n3,p�Madw:C4�r2). $ ICLAIMS-MADE IX I OCCUR MED EXP(Any gnexgrfi rl)......,$.. 5,,000 X Host Liquor PERSONAL&ADV INJURY $ 1,000,000 B X Medical Expense US759652 06/09/2017 07/12/2017 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000 X d POLICY I I JOLT' I I LOC ..,, ....$ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY.I............... NJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY( Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE $ _ HIRED AUTOS (Per accident) NON-OWNED AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ W03KERSCOMPENSATION VVV,.�ot;vu- UT" AND EMPLOYERS'LIABILITY Y/N TORY LIMITS -ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) EL 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,it 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 0710912017-07/09/2017 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 Street El Segundo, CA 90245 AUTHORIZED REPRESENTATIVE ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. POLICY NUMBER: 12342859 COMMERCIAL GENERAL LIABILITY CG 20 11 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - MANAGERS OR LESSORS OF E' EMISES 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, 9C 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, 9C 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: 12342859 COMMERCIAL GENERAL LIABILITY CG 20 26 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OIL ORGANIZATION IIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE 4 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 0413 ©Insurance Services Office, Inc., 2012 Page 1 of 1 POLICY NUMBER: 12342859 COMMERCIAL GENERAL LIABILITY CG 20 12 07 98 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - STATE OR POLITICAL SUBDIVISIONS - PERMITS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE State Or Political Subdivision: As submitted to company and required by written contract, (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) Section II — Who Is An Insured is amended to 2. This insurance does not apply to: include as an insured any state or political subdivi- a. 'Bodily injury,""property damage"or"personal sion shown in the Schedule, subject to the following and advertising injury" arising out of opera- provisions: tions performed for the state or municipality; 1. This insurance applies only with respect to opera- or tions performed by you or on your behalf for b. 'Bodily injury" or "property damage" included which the state or political subdivision has issued within the "products-completed operations a permit. hazard". CG 20 12 07 98 Copyright, Insurance Services Office, Inc., 1997 Page 1 of 1 ❑ Cdhrornia Auto hisurance Identification Card Amer1prise Issued bV IDS F'roperty Caswalty InSUMI'AGO. COIT11D(w 2016 LINC MKZ NAIL 29068 ' 3LNUM93GR602026 3500 Pzv.,.kedand Diivi Policy Number D, Flere, VVI 54.1 15 9070 BX01804833 Effective 01/24/2017-07/24/2017 Narned Insured(s) Drivers Robert A Levine Robert A Levine CITY OF EL SEGUNDO WORKERS'COMPENSATION DECLARATION W'ARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE' IS UNLAWFUL AND SUBJECTS AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL PANES UP TO ONE HUNDRED,THOUSAND DOLLARS($1100,000), 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: C_)I hove and will maintain a certificate of consent of self.insurs for workers'compensation,Issued by the Director of Industrial Relations as provided for by Labor Code 4 3700 for the performance of the work set forth the agreement with the City of El Segundo, Policy No. W (J 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 , m Phone N .... I I certify that,in the performance of the work set forth In the agreement with the City of El Segundo,I Mil not . oIoy any parson 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, ; � o� ,m��g raams.nµt,�.S° IN automatically V become void. Si g nature of Applicant D ate � r... Agreement for;L I Dated: Reviewed by: 'I