PROOF OF INSURANCE (2017) CLOSED CERTIFICATE OF LIABILITY INSURANCE DATE 07/13/2017rn
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 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
NAME:
HCC Specialty PHONE Et1: FAX
PE, x (A/C
.
Nr)
401 Edgewater Place, Suite 400 ADDRESS:
_AODT ER .. -.
Wakefield, MA 01880q)$T( ERII] „... .....
INSURERIS)AFFORDING COVERAGE NAIC#
INSURED INSURERA: New Hampshire Insurance Company 23841
RB
Kimbrough, Dax INSUREStates Fire Insurance Company 21113
.. . United
2119 Dewey St INSURERC:
Santa Monica, CA 90405 INSURERD:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY
PERIOD INDICATED, NOT'W'ITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO
WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY'THE POLICIES DESCRIBED HEREIN IS SUBJECT
TO ALL.THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
ILTR TYPEOFINSURANCE INDDL
SR ISUB FOL..., FDPOLTCTIE F i�(7LI �P kP ....... ........
ICY NUMBER fMMDNYY'Y$ (MM/DWYYYY) LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
A occuR X SEL012343249 06/26/2017 08/08/2017 .wP EMM75G�Trso� rs ^^^^ 5,000
.mX....�.,O CLA MIS-MADEERA❑L LIABILITY MED EXP(An 300,00......
X Host Liquor PERSONAL&ADV INJURY $ 1,000,000
B .X Medical Expense US760197 06/26/2017 08/08/2017 GENERAL AGGREGATE .. $X................................ww
........_ 2,0000,,000000
m X� POLICY AGGREGATE DC7( APPLIESOC. PRODUCTS-COMP/OP AGG_ ._$ 1,000,000
.. .....................ww.
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
ANY AUTO (Ea accident) ..........................................
BODILY INJURY(Per person) $
ALL OWNED AUTOS .......- _..
BODILY INJURY(Per accident) $
SCHEDULED HIRED AUTOS OTOS (Per accident)..........D...............
— PROPE TY AMAGE $
NON-OWNED AUTOS _............................................................... $
$
UMBRELLA LIAR CUR.. . ..._...., ... I.._... ....00CURRENCE $
EXCESS LIAR CLAIMS-MADE
AACGG REGA E.......................wwww.. $
DEDUCTIBLE $
RETENTION
KERS
Ulm
A DjEMPLOY RS'COMPENSATION BILITY Y/N W�� QRY LIMITS.-._ ER.$.............................................
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $
EXCLUDED?
(M nddescr be In anderE.L.DISEASE-EA EMPLOYEE $
it y
DESCRIPTION OF OPERATIONS below E.L.DISEASE•POLICY LIMIT $
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more apace Is required)
The Certificate Holder is added as Additional Insured with respects to our Insured's operations only,
This insurance is primary and non-conlribulory as required by wrillen contract
This coverage is with respect to Centennial Summer Concert Series event to be held 08/06/2017-08/07/2017 at Library Park EI Segundo CA
fL111111111
CERTIFICATE HOLDER CANCELLATION
BEFORE HE EXPIRATION ATE THEREOF,
City of EI Segundo DESCRIBED POLICIES BE CANCELLED
NOTICE WILL BE DELIVERED
350 Main St. IN ACCORDANCE WITH THE POLICY PROVISIONS.
EI Segundo, CA 90245
AUTHORIZED REPRESENTATrq
ACORD 25(2010/05) ®1988-2010 ACORD CORPORATION. All rights reserved.
POLICY NUMBER: 12343249 COMMERCIAL GENERAL LIABILITY
CG 20 11 04 13
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):
As submitted to company and required by written contract.
Name Of Person(s) Or Organization(s) (Additional Insured):
As submitted to company and required by written contract.
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
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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.
affirm under penalty of perjury under the laws of California one of the following declarations:
(� 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 EI 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 EI Segundo is executed. My workers' compensation insurance
carrier and policy number are:
Carrier Policy Number Expiration Date
Name of Agent Phone#
(_x) I certify that, in the performance of the work set forth in the agreement with the City of EI 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 subject to the workers' compensation provisions of Labor Code § 3700 1
must;immediately wf h tho e isions a eenaent ill automatically become void.
Signature of Applicant _. Date 7/18/17
Agreement for:
Dated: �D
Reviewed by:
1