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PROOF OF INSURANCE (2017) CLOSED
OREO .,, 1NIMDATE( 1DDIYYYyf) CERTIFICATE OF LIABILITY INSURANCE 08/0212017 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 ce'rt'ificate does not confer rights to the certificate holder in lieu of such end'orsoment(s), PRODUCERLiberty United Insurance Services,Inc l Ecr Sam MuradyanPHOF oy,8882656899 704 S Victory Blvd,Suite 204 E I 8167616656 Q rAIC.N Burbank,CA 91502 AOORESS: S'amyl°Ptacyrtyalraltedins'yararrce.com License#:OF89841 .„ INSURERISIAFFORDING COVERAGE NAICS INSURER A: United States Fire Insurance Co INSURED INSURER B: Elite Special Events,Inc INSURER C: Q 11278 Los Alamitos Boulevard#101 INSURER 0: Los Alamitos,CA 90720 INSURER E: MURERF: q ---- COVERAGES CERTIFICATE NUMBER: 00000000.279009 REVISION NU'MBE'R: 126 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE'LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT VIATH RESPECT TO WHICH THIS CERTIFIC'A'TE 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 SHOT MAY HAVE BEEN REDUCED BY PAID CLAIMS. 611'SR" yADM SCNSH POLICY EFF yy POLICY exp-LTR TYPE OF INSURANCE 1 POLICY NUMBER IM'MIDDIYYYY1 I IM Y1 LIMITS A X COMMERCIAL GENEtALLIABILITY Y N SRPGP-101-0716 10/28/2016 1012812017 EACH OCCURRENCE s 1,r000,0Q0 CLAIMS-MADE a OCCUR PREWiylS S;E.0C.' 1 Is 300.000 _............ s nyPERSONAL .._. ........... r 5 000 ysapvlwulty s1,0..00000 GIE'N�L,AGGR'EGATELIMITAPPLIESPER: GENERAL AGGREGATE $ 2,000,000 POLICY E JJ'ECT ❑LOC PRODUCTS-COMPMPAGG V S 2,000'OOO OTHER: NpNPVVVV 5 AUTOMOBILE LIAINUTY COfA81NE'O rANGLEUMIT S L - adeng1 ANY AUTO BODILYINJURV Per AUTOS SCHEDULED ..__....... ..BODILY INJURY(PerecdtlenU..5........_.................._......_. . .....m AUTOS ONLY AUTOS "'(y O0"'�'(Y DAMAGE HIRED NON-OWNED ® AUTOS ONLY AUTOS ONLY nky S UMBRELLA U40 OCCUR EACH OCCURRENCE S EXCESS LIAO CLAIMS-MADE �i AGGREGATE S PEDI N RETENTIONS S 'WORKERS COMPENSATION I PErt ORI1y- AND EMPLOYERS`UABILaTY YIN ANY PROPRIElOWPARINeRIMCUTNE OFFICERIMEMSERE=LUC NIA EL EACH ACCIDENT S rr's.tlr In NH' E.L.DISEASE-EA EMPLOYE S yy��z.rarrl�xiba wyairr � _._.................._........... —_. pESCRIPT9ON OF GPE&TATtlON9below EL DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS II=-nONs I=-nONs I VEHIcLES(ACORD 101,Additional Ramorka Schedule,may be attached 11 mon apace b nquked) . City of EI Segundo,its officers,officials,employees and volunteers are listed as additional insureds Scheduled activities exclusion endorsement applies:Mechanical Bull,Mechanical Surfboard,Zip Line,&Permanent Rock Wall Structure CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN City of EI Segundo ACCORDANCE Wm1 THE POLICY PROVISIONS, 350 Main Street EI Segundo,CA 90245 AUTH RE'PRESEarT TI I � r 01988.2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD Printed by SMS on August 02,2017 at 12:36PM COMMERCIAL GENERAL LIABILITY CG 20 26 07 04 THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION Policy Number: SRPGP-101-0716 Insured: Elite Special Events, Inc This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s)Or Organization(s) City of EI Segundo, its officers, officials, employees and volunteers 350 Main Street EI Segundo, CA 90245 Information required to complete this Schedule,if not shown above will be shown in the Declarations. Section II-WHO IS AN INSURED is amended to include as an insured the person(s)or organization(s) shown in the Schedule,but only with respect to liability for"bodily injury","property damage"or"personal and advertising injury"caused,in whole or in part,by your acts or omissions of the acts or omissions of those acting on your behalf: A.In the performance of your ongoing operations;or B.In connection with your premises owned by or rented to you. CG 20 26 07 04 0 ISO Properties,Inc.,2004 Page 1 of 1 A(t �� DATE(MM/DDNM) ,,. CERTIFICATE OF LIABILITY INSURANCE 1 3/13/2017 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 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 Dave Warren .N A Ml,i"E...................................................................................... Nielsen McAnany Insurance Services, Inc. PHONE (805)379-8801 FAX (eos)zoa-asol 4165 E. Thousand Oaks Blvd )) ...�.ar, 'Nr,). Suite 325 ERS ................. INSURER(S)_...... .( )AFFORDING COVERAGE ............ NAIC# Westlake Village g CA 91362Insurance INSURER A:California Auto 38342 INSURED INSURER B ELITE SPECIAL EVENTS, Inc. INSURER C: 404 N Sparks St INSURER D: INSURER E: Burbank CA 91506-1963 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1691303478 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 3OLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. SSR NASD POLICY NUMBER IWNMID((NYYYYI I'WV�VODPMY. TR TYPE OF INSURANCE I LIMITS - CLAIMS-MADE LIABILITY EACH OCCURRENCE $ COMMERCIAL GENE L..�OCCUR 'Ph'�viA6�..�"tJ..I�.tN9`LC�..................... — EM,I$, 5,( aw,�currerr $ D i X,P,(",one person) $ PERSONAL& DV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ OTHER; PR JET PRODUCTS-COMP/OP AGG $ POLICY LOC ......... $ . AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 0 mm.. COSI&nccdenl) 1, 11040000023533 8/31/2016 8/31/2017 BODILY INJURY(Peraca '........Y.yJ.J 00 A X ANY AUTO BODILY INJURY Per person) $ ALL OWNED " SCHEDULED dent) $ AUTOS AUTOS _ Theft Prevention Authority.. HIRED AUTOAUTOS $ S P rt c_; enM1�.. NON-OWNED OAMA E ' UMBRELLA LIAR EXCESS LIAR CLAIMS-MADE AGGREGATERRENCE $ $ DED RETENTION$ $ WORKERS COMPENSATION p PER OTH- AND EMPLOYERS'LIABILITY Y/N .....d_.57ATVj _..L............N..-FR .........-.--____— ANY (Mandatory In H)lEXCLUDE EXECUTIVE �,"'-"".'...I NIA E.L.ITD SC.......A�..............E............................. .a..., J H CIDENT (Mandatory In H)EXCLUDED? EASE EA EMPLOYEE, $ - IDf as.describe under ASE-POLICY LIMIT. .............. ESCRIPTION OF OPERATIONS below E L DISE T $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Certificate Holder and City of El Segundo, its officers, officials, employees, agents, and volunteers. CERTIFICATE MOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of El Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. E1 Segundo, CA 90245 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS025(201401) 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 EI Segundo. Policy No. U 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# (6 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 Califomia, and agree that, if I should become subject to the workers' compensation provisions of Labor Code § 3700 1 must immediately comply with those provisions or the agreement will automatically become void. Signature of ApplicantDate . - ... ..�.., Agreement for: Dated: l\�' Reviewed by: 1