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PROOF OF INSURANCE (2017 - 2018) CLOSED ' ° '"W> CERTIFICATE OF LIABILITY INSURANCE D09/27/2017Y) 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(les) must be endorsed. If SUBR'OGA'TION 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 CON IAGI I NAME: HCC Specialty HONE AI ,I Xty: FAX i C `t (A/C,No): 401 Edgewater Place, Suite 400 ADDRESS PRODUCER Wakefield, MA 01880 CUSTOMER ID U INSURER(S),AFFORDING COVERAGE NAIC# INSURED . .., INsuRERA: New Hampshire Insurance Company 23841 Dan Medina INSURER B: United States Fire Insurance Company 21113 1475 W. 157 Street#C INSURER C: Gardena, CA 90247 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 OIC MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND COND11 IONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPE OF INSURANCE POLICY NUMBER (MM/DD/YYYY) V (MM/D i4s DD UB PO POLICYEFF'' . ' POLICY EXP .. LIMITS D/XXYX) GENERAL LIABILITY I EACH OCCURRENCE $ 1,000,000 A X X OOSEL013687872 10/02/2017 10/10/2017 DAMAGE PREMISESMED FSP((x one prep ) � 5,000 I CLAIMS-MADE GENERAL LIABILITY S-MADE �X, OCCUR RENTED 30Q000 X Host Liquor PERSONAL&ADV INJURY $ 1,000,000 B X Medical Expense US964451 10/02/2017 10/10/2017 GENERAL AGGREGATE $ 2,000,000 X POLICY AGGREGATE LIMIT APPLIES PER: PROD U,CTS-COMP/OG1,000,000 I�"+P1('7- PAG $ JECI LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO a accident) BODILY INJURY(Per person) $ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY(Per accident) $ PROPERTY DAMAGE $ HIRED AUTOS (Per accident) NON-OWNED AUTOS $ U $ UMBRELLA LIAB OCCUR EACH OCCURRENCEEXC $ ESS LIAB l CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION VAt,61wlt7- vera AND EMPLOYERS'LIABILITY Y/N ,TD9Y I,IhAITR, _F9 „ ANY PROPRIETOR/PARTNER/EXECUTIVE I""""" - E.LEACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E1 DISEASE-EA EMPLOYEE' $ II yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule if mores ace is required) P 4 ) 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 written contract This coverage is with respect to EI Segundo Centennial Celebration event to be held 10/07/2017-10/07/2017 at EI Segundo Library Park EI Segundo CA CERTIFICATE HOLDER CANCELLATION City of EI 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. EI Segundo, CA 90245 AUTHORIZED REPRESENTATIVE ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. POLICY NUMBER: 13687872 COMMERCIAL GENERAL LIABILITY CG 20 11 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - MANAGERS O LESSORS OF PREMISES This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART ^„ SCHEDULE log Designation Of Premises (Part Leased To You): City of EI Segundo, its officers, officials, employees, agents, and volunteers, 350 Main St., EI Segundo, CA, 90245 Name Of Person(s) Or Organization(s) (Additional Insured): City of EI Segundo, its officers, officials, employees, agents, and volunteers, 350 Main St., EI Segundo, CA, 90245 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 ©Insurance Services Office, Inc., 2012 Page 1 of 1 TEMPORARY CALIFORNIA EVIDENCE OF LIABILITY INSURANCE TEMPORARY CALIFORNIA EVIDENCE OF LIABILITY INSURANCE MERCURY California Automobile A MERCURY California Automobile INSURANCE Insurance Company INSURANCE Insurance Company AGENCY.GARDENA GENERAL INS AGENCY(310)327-1000 AGENCY:GARDENA GENERAL INS AGENCY(310)327-1000 POLICY NUMBER EFFECTIVE & EXPIRATION DATES POLICY NUMBER EFFECTIVE & EXPIRATION DATES 0401 07 150122830 07/31/2017 01/31/2018 0401 07 150122830 07/31/2017 01131/2018 YEAR MAKE VEHICLE IDENTIFICATION NUMBER YEAR MAKE VEHICLE IDENTIFICATION NUMBER 2004 VOLVO YV1TS59H741381904 2004 VOLVO YVITS59H741381904 NAMED INSURED NAMEDINSURED DANIEL MEDINA DANIEL MEDINA TO REPORT A CLAIM,please call(800)503-3724 TO REPORT A CLAIM„please call(800)$$03.3724 For access to ROADSIDE ASSISTANCE ONI..Y',please call(866)519-6478 For access to ROADSII:IE ASSISTANCE ONLY,pl'ea,", �call(866)519,5418 This insurance corrlplius with CVC S16056 or 516500 5 MAIC#38342 This insurance carnplies wwdh l,VC S160r;6 or 516500 6 NAIC41-:11134'2 fold in half here fold In half here 555 W.Imperial Highway,Brea,CA 92821 555 W.Imperial Highway,Brea,CA 92821 THE COVERAGE PROVIDED BY THIS POLICY MEETS THE THE COVERAGE PROVIDED BY THIS POLICY MEETS THE MINIMUM LIABILITY LIMITS PRESCRIBED BY LAW MINIMUM LIABILITY LIMITS PRESCRIBED BY LAW IF YOU HAVE AN ACCIDENT IF YOU HAVE AN ACCIDENT Notify the police immediately, Notify the police immediately. Capture the names,addresses,telephone numbers,driver license numbers Capture the names,addresses,telephone numbers,driver license numbers and license plate numbers of all persons involved and of witnesses, and license plate numbers of all persons involved and of witnesses Note any damage to other vehicles Note any damage to other vehicles, Do not admit fault Do not discuss the accident with anyone except your Do not admit fault,Do not discuss the accident with anyone except your agent,Mercury or the police. agent,Mercury or the police. Immediately report all claims to Mercury at(800)503-3724 Immediately report all claims to Mercury at(800)503-3724 «.w Take ih otarl:lf o!sahle rev m « nla,..l,.. 7/14 �"-`_-I____.. 07/14 ........... ......._A.'...eahaaBwrwul�l.aarswrltle,___—__�,__,...._..,..._.,,....,...... rev..dr..._, MMKICUORky INSUR NICE TEMPORARY INSURANCE IDENTIFICATION CARD Temporary ID Card - Do Not Mail to DMV TEMPORARY CALIFORNIA EVIDENCE OF LIABILITY INSURANCE TEMPORARY CALIFORNIA EVIDENCE OF LIABILITY INSURANCE ' MERCURY California Automobile �y MERCURY California Automobile .! INSURANCE Insurance Company M INSURANCE Insurance Company AGENCY:GARDENA GENERAL INS AGENCY(310)327-1000 AGENCY.GARDENA GENERAL INS AGENCY(310)327-1000 POLICY NUMBER EFFECTIVE & EXPIRATION DATES POLICY NUMBER EFFECTIVE & EXPIRATION DATES 0401 07150122830 07/31/2017 01/31/2018 0401 07 150122830 07/31/2017 01/31/2018 YEAR MAKE VEHICLE IDENTIFICATION NUMBER YEAR MAKE VEHICLE IDENTIFICATION NUMBER 1975 DODGE F34F5V015304 1975 DODGE F3F5V015304 NAMED INSURED NAMED INSURED DANIEL MEDINA DANIEL MEDINA TO REPORT A CLAIM,please call(800)503-3724 TO REPORT A CLAIM,please call(800)503-3724 For access to ROADSIDE ASSISTANCE ONLY,please call(866)519-6478 For access to ROAI'lt';a'113E ASSISTANCE ONLY,please call(8tit'�,i 510.6478 This insurance ealca'rg�Ws with CVC S16056 or 516500 5 NAIC#38342 'I"h�iw i�l'u^ar.aranco compldoa rowrpin fw''V'4,,:v1ti0"�1:5 or S'tt15110 5 NAIC038342 fold in half here fold in half here 555 W.Imperial Highway,Brea,CA 92821 555 W.Imperial Highway,Brea,CA 92821 THE COVERAGE PROVIDED BY THIS POLICY MEETS THE THE COVERAGE PROVIDED BY THIS POLICY MEETS THE MINIMUM LIABILITY LIMITS PRESCRIBED BY LAW MINIMUM LIABILITI'LIMITS PRESCRIBED BY LAW IF YOU HAVE AN ACCIDENT IF YOU HAVE AN ACCIDENT Notify the police immediately Notify the police immediately, Capture the names,addresses,telephone numbers,driver license numbers Capture the names,addresses,telephone numbers,driver license numbers and license plate numbers of all persons involved and of witnesses, and license plate numbers of all persons involved and of witnesses Note any damage to other vehicles. Note any damage to other vehicles Do not admit fault Do not discuss the accident with anyone except your . Do not adrift fault Do not discuss the accident with anyone except your agent,Mercury or the police agent,Mercury or the police Immediately report all claims to Mercury at(800)503-3724 Immediately report all claims to Mercury at(800)503-3724 Take photos if possible rev 07/14 Take photos if possible, rev 07/14 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. C_)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# (_J 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 eco ubjecZc the workers' compensation provisions of Labor Code § 3700 1 must immediately comply with t e ov aio h agreement will automatically become void. . Signature I' r�'� Date Agreement for: Dated: Reviewed by 1