PROOF OF INSURANCE (2018) CLOSED "1� 9/77/201/201YYYY)CERTIFICATE OF LIABILITY INSURANCE DATE( II
7
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
25422 TRABUCO RD#105-006 PHOra w W W-. w..�prr
AMUSEMENT&EVENT PLANNERS INSURANCE SPECIALISTS
A/C No,Ext): 866-380-3372 (A/C Nol,:
LAKE FOREST,CA 92630-2791 E»MAIL
ADDRESS,
866-380-3372
INSURER(S)AFFORDING COVERAGE NAIC q �
INSURERA: United States Fire Insurance 21113
........... ......................___.........._ ....................... ....................__......_.......-._..._.......�..-.........._..........._....._... ..........__.... ................__............_ ......................�
INSURED SPORTS AND RECREATION PROVIDERS ASSOCIATION(PURCHASING GROUP)AND INSURERS:
ITS PARTICIPATING MEMBERS:
INSURER C:
Ron lacopucci dba Jump For Joy INSURERD:
530 S Francisca Ave
Redondo Beach,CA 90277 INsuREREc
INSURERFp
COVERAGES CERTIFICATE NUMBER: USP251757 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 DOLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTRI
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INSR TYPE OF INSURANCE ADDL SUER, POLICY NUMBER POLICY EFF POLICY EXP LIMITS
NSR WVD fMMIDD/YYYYI (MMIDDIYYYY) II
GENERAL LIABILITY V GENERAL AGGREGATE $2,000,000,00
X COMMERCIAL GENERAL LIABILITY n PRODUCTS-COMP/OP AGG $2,000,000,00
—1 CLAIMS-MADE lx:lOCCUR 1 PERSONAL&ADV INJURY $1,000,000.00
A X SRPGP-101-0717 12:01 AM 02:01 0181 EACH OCCURRENCE $1,000,00000
12:01 AM 12:01 AM
.....................--..........................--......------- FIRE DAMAGE(Any one fire) $300,000.00
GENLAGGREGATE LIMITAPPLIES PER: I MED EXP(Any one person) $5,000,00
..,.X POLICY �... „JECT ITIT.,IT�LOC
. .... PRO- . .._
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED BODILY INJURY(Per accident) $
ALTO AUTOS
....� HIRED AUTO NON-OWNED
-.........,AUTOS ....(ParO„ercldant,)iM1P'wIFti3............................_...,.,.,.,$,...,...,...,...,...,.,.,.,.,.,.,.,.,..�W_____._._„
R.,. �,....�.�...
......._ 1"-
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UMBRELLA LIAR occuR EACH OCCURRENCE
EXCESS LI IA'R CLAIMS-MADE AGGREGATE $
DED I II RETENTION $
_ RRR EACH OCCURRENCE $
GENERAL AGGREGATE $
EACH OCCURENCE
GENERAL AGGREGATE
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required)
Inflatable Rentals and Party Supplies
The Certificate Holder is added as an additional insured but only with respect to liability arising out of the named insured during the policy period.
Scheduled Activities Exclusion Applies-Please Refer to Named Insured Member Certificate of Coverage
CERTIFICATE HOLDER CANCELLATION
City of EI Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
350 Main Street ACCORDANCE WITH THE POLICY PROVISIONS.
EI Segundo, CA 90245
AUTHORIZED REPRESENTATIVE
Amusement & Event Planners Insurance
Specialists
ACORD 26(2010/05)v141120.001 ®1988-2010 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
COMMERCIAL GENERAL LIABILITY
CG 20 26 07 04
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL ITIONAL I SUREU - DESIGNATED PERSON: OR
ORGANIZATION
Policy Number: SRPGP-101-0717/USP251757
Insured: Ron lacopucci dba Jump For Joy
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
NameOf Additional Insured Person(s) Or Organization(s)
City of EI Segundo
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 C ISO Properties, Inc., 2004 Page 1 of 1 ❑
w VEL J
Automobile Policy Continuation Declarations
1. Named Insured Your Service Center Address
RON &VALERIE IACOPUCCI KNOXVILLE BUSINESS CENTER
530 S FRANCISCA AVE APT#B P O BOX 59059
REDONDO BEACH, CA 90277-4241 KNOXVILLE, TN 37950-9059
Your Insurer
TRAVELERS COMMERCIAL INSURANCE COMPANY
ONE TOWER SQUARE, HARTFORD, CT 06183
Your Auto Policy Number 996024601 203 1 For Policy Service 1-800-842-5075
Your Account Number 941113867 For Claim Service 1-800-252-4633
2. Premium
Your Total Premium for the Policy Period is $1,437.
The policy period is from August 1, 2017 to February 1, 2018 12:01 A.M. STANDARD TIME at your address
shown in Item 1.
3. Your Vehicles Identification Numbers
1. 2006 TOYOT TUNDRA LIM 5TBDT481265519837
2. 1990 FORD F350 2FDKF37M1LCA88678
h 3. 2001 TOYOT AVALON XL/ 4T1 BF28B11 U131498
e 4. 2010 TOYOT PRIUS JTDKN3DUXA0148831
4. Coverages, Limits of Liability and Premiums
Insurance is provided only where a premium entry is shown for the coverage. The premium entry"Incl' or"Pkg"
means the premium charge is included in the premium for another coverage or a package.
VEHICLE 1 VEHICLE 2 VEHICLE 3 VEHICLE 4
06 TOYOT 90FORD 01 TOYOT 10 TOYOT
TUNDRA LIM F350 AVALON XL/ PRIUS
A. Bodily Injury
$100,000 each person
$300,000 each accident $196 $225 $141 $167
B. Property Damage
$50,000 each accident $92 $80 $54 $66
D1. Uninsured Motorists Bodily Injury
$100,000 each person
$300,000 each accident $47 $62 $47 $47
E. Collision
Actual Cash Value less
$2,500 deductible $61 $29 $74
T. Waiver of Collision Deductible $2 $2
PL-50014(03-12) Pagel of 4
670/OM 1605
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:
(—) 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 El Segundo is executed. My workers'compensation insurance
carrier and policy number are:
Carrier Policy Number Expiration Date
Name of Agent _ Phone#
(.�J 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 subject to the workers' compensation provisions of Labor Code § 3700 1 must
immediately comply witVt �A rovisi ns�ortagreement will automatically become void.
Signature of Applicant t°.� '�'�' Date
Vi=a
Agreement for:
Dated: �M `
Reviewed b _ _ ....
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