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PROOF OF INSURANCE (2017 - 2018) CLOSED AC">�`[� DATE(MMIDDIYYYY) �. CERTIFICATE OF LIABILITY INSURANCE 1 9/14/2017 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(ie's) 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 BB Of PA NAME (LAI A . Brown 6 Brown of PA (484)567-0150 � 125 E Elm Street ADDRCMIIa I F* (AJc�IQ ). (484)567-0158 SS:name@bbofpa.com Suite 210 INSURER(S)AFFORDING COVERAGE NAIC# Conshohocken PA 19428hiladelphia Indemnity,Ins Co 18058 INSURED INSURER B,URER .. . Fantastick Patrick Productions LLC INSURER B: 11131 Rose Ave INSURER D: 13 INSURER E: Los Angeles CA 90034 INSURER F: COVERAGES CERTIFICATE NUMBER:17/18 REV'ISI'O'NNUMBER: 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, „ TYPEOF„,,,,,,,,, I,I�ISO SUBR WVD POLICY NUMBER.... .... LTR INSURANCE POLICY EFF POLICY E)&P LIMITS IMMIDD)YYV'Y) (MMtO'pdVYYY) LIABILITY EACH OCCURRENCE $ 1,000,000 A XCO CLAIMS-MADE R I OCCUR PREMDAMAGEIbkENI'IEY� 100,000 L GENERAL g p X PHPK1581711 5/15/2017 5/15/2018 MED EXP E Any one person) $ 0 D Ded•„ PERSON GEN'L AGGREGATE LIMIT APPLIES PER, GENERAL &ADV INJURY $ 1,000,000 R POLICY RNERALAGGREGATE �$ 2,000,000 IJECOT1. PRODUCTS $ 2,000,000 LOC P.......... f ..........„„ OTHER 1 $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (FA,w,idenl'), ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident)i$ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS (Per j�cod�artfl „ UMBRELLA LIAB CUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED ( RETENTION$ $ WORKERS COMPENSATION PER ()T'H- AND EMPLOYERS'LIABILITY YIN S'[�,TLMTE I ER . ANY I (MFFI andatR/ryEn B H)EXCLUDED?ECUTIVE N I A EL DASEASECIEA ACCIDENT $ EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below EL DIM,EASE•P(',)LIICY I.IWT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Member ID# B170322 City of E1 Segundo has Additional Insured status per attached form CG-2010, which is included in the policy, while the Named Insured is "on premises". CE'RTIFI'CA'T'E HOLDER. CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of El Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN E1 Segundo, CA ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE James Toennies/MICK ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025rgmamt POLICY NUMBER: PHPKI581711 COMMERCIAL GENERAL LIABILITY CG 20 10 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES O CONTRACTORS - SCHEDULED PERSON O ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Location(s) Of Covered Operations Any persons or organizations as required by written contract executed prior to a loss. 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 additional organization(s) shown in the Schedule, but only exclusions apply: with respect to liability for "bodily injury", "property This insurance does nota I to "bodily " or damage" or "personal and advertising injury" property damage occurring after: apply injury" caused, in whole or in part, by: 1. Your acts or omissions; or 1. All work, including materials, parts or equipment furnished in connection with such 2. The acts or omissions of those acting on your work, on the project (other than service, behalf; maintenance or repairs) to be performed by or in the performance of your ongoing operations for on behalf of the additional insured(s) at the the additional insured(s) at the location(s) location of the covered operations has been designated above. completed; or However: 2. That portion of "your work" out of which the injury or damage arises has been put to its 1. The insurance afforded to such additional intended use by any person or organization insured only applies to the extent permitted by other than another contractor or subcontractor law; and engaged in performing operations for a 2. If coverage provided to the additional insured is principal as a part of the same project. 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 10 04 13 ©Insurance Services Office, Inc., 2012 Page 1 of 2 C. With respect to the insurance afforded to these 2. Available under the applicable Limits of additional insureds, the following is added to Insurance shown in the Declarations; Section III—Limits Of Insurance: whichever is less. If coverage provided to the additional insured is This endorsement shall not increase the required by a contract or agreement, the most we applicable Limits of Insurance shown in the will pay on behalf of the additional insured is the Declarations. amount of insurance: 1. Required by the contract or agreement; or Page 2 of 2 ©Insurance Services Office, Inc., 2012 CG 20 10 04 13 Progressive D/RECTAuto PO Box 31260 Tampa,FL 33631 Policy Number: 907970565 Underwritten by: United Financial Cas Co Policyholders: Nicholas T Paul Kristen M Paul September 14,2017 Page 1 of 1 Customer Service 1-800-776-4737 24 hours a day,7 days a week Mailing Address: Progressive PO Box 31260 Tampa,FL 33631-3260 Requested! ol"Icy documents ❑ Verification of Insurance Progressive PR949REW11F PO Box 31260 01RECTALito Tampa,FL 33631 MAIC Company Code 11770 Policy Number: 907970565 Underwritten by: United Financial Cas Co Policyholders: Nicholas T Paul Kristen M Paul Page 1 of 1 September 14,2017 Customer Service 1-800-776-4737 24 hours a day,7 days a week I I V ' caI f i' t"on of Insfo urance r erl , Nicholas T Paul and Kristen M Paul This verification of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policies listed herein. Notwithstanding any requirement,term or condition of any contract or other document with respect to which this verification of insurance may be issued or may pertain,the insurance afforded by the policies described herein is subject to all the terms,exclusions and conditions of the policies. Please accept this letter as verification of insurance for this policy. Policy and driver information Policy number: 907970565 Policy state: Cahlonnia Policy period: May 20,20117 Nov 20,2017 There was nolapse in coverage during this policy period. . 1. . ... .....1.1.11 . ...... ....... Effective date: May 20, 2017 Drivers. N'icholas T Paul I,nsured I Dr,iver . . . . . . . Kristen M Paul Insured Driver Address: 5416 Fair Ave Apt 8215 North Hollywood,CA 91601 Vehicle information Vehicle: 2015 Kia Soul Vehicle identification number: KNDJP3A57F7757862 ............. Lienholder: KIA MOTOR FINANCE CO PO Box 20809 FOUNTAIN VALLEY,CA 92728 Coverage information Bodily Injury Liability: $100,000 each person/$300,000 each accident Property Damage Liability: $100,000 each accident ... ..... ........... .... ... . . . . . .. .......... Collision: Deductible: $500 deductible Comprehensive: Deductible: $500 deductible kun V'A 0//1>) 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 EI Segundo is executed. My workers' compensation insurance carrier and policy number are: Carrier Policy Number Expiration Date Name of Agent Phone# (V) 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 comply with those pro ' ions or the reement will automatically become void. Signature of Applicant Date 9/14/17 Agreement for. Dated: Reviewed by: u 1