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PROOF OF INSURANCE (2017 - 2018) CLOSED DATE(MMIDD/YYYY) CERTIFICATE OF LABILITY INSURANCE 11/09/2017 PRODUCER THIS CERTIFICATION IS ISSUED AS A MATTER OF INFORMATION East Main Street Insurance Services, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Will Maddux HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR PO Box 1298 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Grass Valley,CA 95945 Phone:(530)477-6521 Email:info@theeventhelper.com INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Evanston Insurance Company 35378 Acts of Creation INSURER B: Chris Shoemaker P.O.Box 802601 INSURER C: Santa Clarita,CA 91380 INSURER D: INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSRADD'L, POLICY EFFECTIVE POLICY EXPIRATION LTR WSRD TYPE OF INSURANCE POLICY NUMBER DATE(MM/DD/YY) DATE(MM/DD/YY) LIMITS GENERAL LIABILITY EACuu H OCCURRENCE mcwoes $ 1,000,000 r+rnc^�ioa,aosrt�rva ruev,unena ryionrd„nd�c A Y X COMMERCIAL GENERd AL LIABILITY . EXP(..A ny one person) .„..$... 5,000 ,ufl ir�,,p ry CLAIMS MADE OCCUR PERSONAL&ADV INJURY $ 1,000,000 X Host Liquor Liability k ,rv„o551 � I6 II I " II II 19/'210 t., I 'mto .n'� GENERAL AGGREGATE $ 2,000,000 E LIMIT APPLIE JECT S PER: PRODUCTS-COMP/OP AGG $ 1,000,000 X POLICY ,_......- PRO- LOC DEDUCTIBLE $ 1,000 Retail Liquor Liability $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) !, GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ $ WC STATU- WORKERS COMPENSATION AND OTH EMPLOYERS'LIABILITY TORY LIMITS ER EACH ACCIDENT $ ANY PROPRIETORIPARTNER/EXECUTIVE E.L. OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ If yes,describe under SPECIAL PROVISIONS below E .DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Certificate holder listed below is named as additional insured per attached CG 20 26 07 04. Attendance:1500,Event Type:Holiday Event-Not Haunted-No Charge for Admission/Invite Only. 7' „f CERTIFICATE HOLDER CANCELLATION THE CITY OF EL SEGUNDO, ITS OFFICERS, SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION OFFICIALS,EMPLOYEES,AGENTS& DATE THEREOF,THE ISSUING INSURER WILL ORKAMGR36MAIL 30 DAYS WRITTEN CERTIFIED VOLUNTEERS 111 West Mariposa Avenue NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, EI Segundo,CA 90245 IGAT"G04 OR h!AB!61*Y OF ANV KIND UPON*HE INSURER,I'S AGENTS OR AUTHORIZED REPRESENTATIVE I ACORD 25(2001/08) 0ACOR'D CORPORATION 1988 Policy Number:3DS5455-M1641127 COMMERCIAL GENERAL LIABILITY CG 20 26 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s)Or Organization(s) THE CITY OF EL SEGUNDO, ITS OFFICERS, OFFICIALS, EMPLOYEES,AGENTS& CERTIFIED VOLUNTEERS 111 West Mariposa Avenue 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 in- clude as an additional insured the person(s)or organi- zation(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 or the acts or omis- sions 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 ©ISO Properties, Inc., 2004 Page 1 of 1 ❑ TEMPORARY AUTO IDENTIFICATION STATE FARM5 This card is invalid if the policy for which it was issued lapses or is terminated. ................ .......................... __......_............................................................_..............._............._...................................... CALIFORNIA CAR INSURANCE CARD & n `gip IIIW'll° Y01 I III""1!AVE A14 ACCH")11111;ll .I. ............................................w.................I'll. .......,,,,. NO"'FllllF1( I110III...II1(" III IIIII;II...Y POLICY NUMBER 3160563-C16-75D INSURED 1.Get names, addresses, and phone numbers of persons involved and SHOEMAKER,CHRIS witnesses.Also get driver license numbers of persons involved and license plate numbers/states of vehicles. 2.Promptly notify your agent,log on to statefarm.comO,or visit State Farm EFFECTIVE DATE NOV-09-2017 EXPIRATION DATE MAR-16-2018 Pocket Agent®to file a claim. CAR-YEAR/MAKENEHICLE IDENTIFICATION NUMBER 3,Don't admit fault or discuss the accident with anyone but State Farm or 2016 FORD ESCAPE SPORT WG police. 1FMCUOF73GUA29819 COVERAGES For Emergency Road Service call 1-877-627-5757 A,C,D100 , 1000,H,R1,U, VVVVVVVVVB°iW IMuiW II iiiiii iiii " ili"iiVlllllli, pµ"""°ry mii I�p " �1iIIIIIC km'k' I VVVV1 The coverage provided b the policymeets the minimum liability limits prescribed by law. NAIC#25178 SEE POLICY FOR FULL NAME AND DEFINITION A Liability R1 Car Rental and Travel Expense State Farm Mutual Automobile Insurance Company C Medical Payments S Death,Dismemberment and 900 OLD RIVER ROAD D Comprehensive Loss of Sight BAKERSFIELD CA 93311-9501 G Collision U Uninsured Motor Vehicle AGENT H Emergency Road Service U1 Uninsured Motor Vehicle-PD ERIC A PLAHN,JR L Physical Damage Z Loss of Earnings 25044 PEACHLAND AVE NEWHALL,CA 91321 PHONE#661-259-2871 Submit this card or a photocopy of this with your vehicle registration renewal. One copy of this form should be carried in the vehicles at all times. The form may be needed as evidence of insurance in court. A toll free number is available for Emergency Road Service and is located on your insurance card. 1001188 2003 144750 200 01-03-2017 CITY OF EL SEGUNDO WORKERS' COIIIIPENSAT"ION DECLARATION WARNING: FAILURE'TO SECURE WORKERS'CO PENSATION 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 COIIIIPENSATION, DAMAGES AS PROVIDED FOR IN LABOR CODE § 3706, INTERTEST, AND ATTORNEY'S FEES. I affirm under penalty of perjury under the laws of California one of the following declarations: L_) I have arra will maintain a certificate of consent of self-insure for workers'compensation, Issued by the Director of Industrial relations as provided for by Lagar 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: Carder Policy Number Expiration Date Name of Agent Phone# Zcertify 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 k+s " cornpeAsation provisions of Labor Code § 3700 l must immediately tomatically become void. Sigture of Applicant with tho � rnen wv� u. . Date Agreement for • Dated. r �� w � Reviewed by: •. 1 � vb I IW " is I I NI I ilN I e C 0 Xh I4 u I w wo, rq ^VI I II i M Y W IW, � I III' I Nyl r 6 a Vti 4 « Y cu Ao `6i I � d w 0) mN Y Iptluul ii V II � X I•"� x III « V - o ryry A w q f X a h I ."1 '+,� 'i'�' �", NA"Y"p Nor" «'"•'"• "„ „II«^N" � �'��1 �'�'�, �; ',�� '� ��'� M"W4 J I » I 1 f d p'14i l 11 N n ��N u % iy Aix % y y I �X pp I d' I X 4 o p s