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ICRMA 2017 - Automobile Driving MuseumIndependent Cities Risk Management Authority 18201 Von Karman Ave., Suite 200, Irvine, CA 92612 949.349.9882 Liability Certificate of Coverage Additional Covered Party Certificate Number: 30699133 Certificate Holder: Automobile Driving Museum 610 Lairport Street EI Segundo, CA 90245 Covered Party: City of EI Segundo Description of RE: City of EI Segundo's Centennial Ball on January 21, 2017. Covered Activity: Certificate Holder is included as an Additional Covered Parry with regard to any negligent acts or omissions of the Covered Party, its employees, and its elected or appointed officials. Memorandum of Coverage Number: ICRMA GL 2016 Effective Date: 7/1/16 Expiration Date: 7/1/17 Limits: $1,000,000 (per occurrence) Self -Insured Retention: $750,000 The Following General and automobile liability as defined in the memorandum of coverage on file with the covered parry Coverage is in effect: named above. This is to certify that the coverage listed above has been issued to the Covered Party named above for the coverage 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 coverage afforded as described herein is subject to all the terms, exclusions, and conditions of the Liability Memorandum of Coverage of the ICRMA, which is available for your review upon request. Pursuant to the definition of Covered Party in the Liability Memorandum of Coverage, the certificate holder named above is an additional covered parry for covered claims arising out of the covered activity stated above and is subject to the limits stated above. Limits shown include the city's SIR. Coverage is in effect from 12:01 a.m. Pacific Standard Time of effective date to 12:01 a.m. Pacific Standard Time of expiration date as stated above and will not be canceled, limited, or allowed to expire except upon 30 -day notice to the certificate holder. Date Issued: 1/13/2017 Renewal: Yes Authorized Representative Signature: *L-4rwl) CERTIFICATE OF INSURANCE Date IY16/2017 Producer This certificate is issued as a matter of information only and confers no rights Verch Insurance Inc. upon the certificate holder. This certificate does not amend, extend or alter the 302 W. Grand Ave #8 coverage afforded by the policies below. :1 Segundo, CA 90245 COMPANIES AFFORDING COVERAGE Phone: 310-322-1626 Company ....................... A IUSLI Insurance Company N,ar ,�„ Letter P15S3169 3PI5_51169 Insured Company B El Segundo Chamber of Commerce Letter 427 Main Street Company C Bodily Letter El Segundo, CA 90245 Company Ise Products/Completed Operations I N0P1 5 169.... Letter D ..I Contractual Companyf.......' ............................................................................................................................. ....... E Property Letter COVERAGES 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 herein is subject to all the terms,exclusions and conditions of such policies. Co, General Liability Policy Number Effective Date Expiration Date Liability Limit in Thousands N,ar ,�„ �,� Comprehensive Form P15S3169 3PI5_51169 „____3�/3Q[201fi,--------- -- Each J���2Q�.%� Occurrence Aggregate Premises/Operations b 1 Bodily Explosion/CollapseUnderground Hazard Injury 1,000,000 V200,000 Ise Products/Completed Operations I N0P1 5 169.... W 31?.Q 010 3/30/201 P ..I Contractual W Property Independant Contractors Damage (u Broad Form Property Damage BI+PD Personal lr jury Combined ) �A, I 'V (l:i001, liability IN¢P1553_169 ( f Q%?��!?� (. (6120 p —) _ — Personal Pro0 Perty Automobile Liability ❑ Any Auto ❑ All Owned Autos (Priv. Pass.) ❑ All Owned Autos (Other than Priv. Pass) ❑ Hired Autos ❑ Non -Owned Autos Garage Hability Excess Liability ❑ Umbrella Form ❑ Other than Umbrella Form Worker's Compensation ❑ and Employers' Liability Other Descri ption of Opcc°atiororoaWT tacationas/4 elriclt s/Sgrorsciaq Items ertIficate holder is additional insured Event date 1/21/2017 Bodily Injury (Per Person) Bodily Injury (Per Accident) Property Damage BI+PD Combined BI+PD u Combined Statutory (Each Accident) (Disease -Policy Limit) (Disease -Each Employee) CERTIFICATE HOLDER CANCELLATION Automobile Driving Museum Should any of the above described policies be cancelled before the expiration date thereof, the issuing 610 Lalrport Street company will endeavor to mail days written notice to the certificate holder named to the left, but failure to mail such notice shall impose no obligation or liability of any kind upon the company, its agents or I Segundo CA 90245. representatives. Authorized Representative Debwfi 2adin a-fflw a POLICY NUMBER: NBP1553169A BUSINESSOWNERS BP 04 48 01 06 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM SCHEDULE Name of Additional Insured Person(s) Or Organization(s): Effective Date: 01/21/2017 12:01 AM Automobile Driving Museum 610 Lairport Street EI Segundo, CA 90245 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The following is added to Paragraph C. Who Is An Insured in Section II - Liability: 3. Any person(s) or organization(s) shown in the Schedule is also an additional insured, 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 or the acts or omissions of those acting on your behalf in the performance of your ongoing operations or in connection with your premises owned by or rented to you. ,P 04 48 0106 0 ISO Properties, Inc., 2004 Page 1 of 1 State of California Department of Alcoholic Beverage Control ABC -281 10/99 License Type: 37 Daily On -Sale General License Nontransferable LICENSE NO. 9489305 Receipt No. 2406719 Fee -Paid $25.00 APPLICATION: Geographical Code 1919 Pursuant to the authority granted by the organization named below, the undersigned hereby applies for the above designated license(s) for the location also described below. ORGANIZATION: EL SEGUNDO CHAMBER OF COMMERCE LOCATION ADDRESS: 610 LAIRPORT ST EL SEGUNDO, CA 90245 TYPE OF EVENT: DINNER/DANCE HR/DATES DURING WHICH January 21, 2017 ALCOHOL WILL BE SOLD: 6:00 PM TO 10:00 PM ESTIMATED ATTENDANCE: 300 AUTHORIZED REPRESENTATIVE /ADDRESS MARSHA 14ENSEN 427 MAIN STREET EL SEGUNDO CA 90245 LICENSE: The above-named organization is hereby licensed, pursuant to Section 24045.1 of the Business and Professions Code and Rule 59.5 of the California Code of Regulations, to engage in the temporary sale of alcoholic beverages for consumption at the above-named location for the period authorized below.This license does not include off -sale ("to -go") privileges. This license may be revoked summarily by the Department if, in the opinion of the Department and/or the local law enforcement agency, it is necessary to protect the safety, welfare, health, peace, and morals of the people of the State. Good for I day(s). Date Issued )411(Ulal'y 19, 2017, D iAo crgeS"oltrot.iiyt0T­AYco By Ca /ifornia State of California RECEIPT FOR PAYMENT Paid For: EL SEGUNDO CHAMBER OF COMMERCE Received at: LB/LAKEWOOD DISTRICT Office Payment Method MONEY ORDER Accounting Comment: Detail Transaction 37 - DGL .., ter,,.... BY: ABC -42 (01/01)I I D# 19719381701 Job # 9489305 Department of Alcoholic Beverage Control Received: January 19, 2017 Receipt No: 2406719 Total Amount: $25,00 Amount Paid By $25.00 EL SEGUNDO CHAMBER OF COMMERCE Dup Unit Cost Quantity Amount Paid 1 1 $25.00 Page 1 of 1