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PROOF OF INSURANCE (2018 - 2018) CLOSED AC CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) il .•--°'" 1 11/10/2017 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(les)must have ADDITIONAL INSURED provisions or 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 NAME: Sam8187618888 ( Libertyradyan United Insurance Services,Inc A o s.Mtl° 818761 bertyunitedinsurance.com AIc 8882656889 704 S Victory Blvd Suite 204 PHONE iiXgNc9, Burbank,CA 91502 SURERIS(AFFORDING COVERAGE NAIC# License#: OF89841 IN INSURERA: United States Fire Insurance Co, INSURED INSURER B Elite Special Events,Inc INSURER C:� 11278 Los Alamitos Boulevard#101 INSURER D: Los Alamitos, CA 90720 INSURER E; INSURER F: COVERAGES CERTIFICATE NUMBER: 00000000-279009 REVISION NUMBER: 153 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 CONTRACTOR 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, INSIR TYPE OF INSURANCE /IDOL 8UBRI Pb ._INSD WVD I POLICY NUMBER (MM�IDWYYYYI (MMIDD(YYYY) LIMITS _ EAC CCURRENCE s co CLAIMS-MADE X OCCUR RF s s RENTED nGea 5 1 300a 00 A "' CLAIMSL GENERAL LIABILITY MED EXP(An one erne It a 5 000 Y N SRPGP-101-0717 10/28/2017 10/28/2018 d Y person) 51000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. ,GENERAL AGGREGATE s 21,000'000 ,}I, POLICY PRODUCTS-COMP/OP AGG C 5 2}, PRO. JECT LOC 2,000,000 OTHER $ AUTOMOBILE LIABILITY COMI SINGLE LIMI'G Me aC00111) ANY AUTO BODILY INJURY(Per person) 5 OWNED SCHEDULED BODILY INJURY Per AUTOS ONLY AUTOS ( accident) 5 HIRED NON-OWNED PRPERTY ------- AUTOS ONLY �...........- AUTOS ONLY (Per'ract,dontp IM'ua IIS UMBRELLA LAB OCCUR EACH OCCURRENCE 5 EXCESS LIAB CLAIMS,MADE AGGREGATE $ DEC) U RETENTION 5 5 WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E,L EACH ACCIDENT 5 OFFICER/MEMBER EXCLUDED? I_____Y N/A (Mandatory in NH) E L DISEASE-EA EMPLOYEE;5 If yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT 5 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) City of EI Segundo,its officers,officials,employees and volunteers are listed as additional insureds Scheduled activities exclusion endorsement applies: Fireworks, Mechanical Bucking Devices: including Multi Ride Attachments, Permanent Rock Wall Structures,Security Forces,Trampolines,and Zip Lines. CERTI'FICA'TE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN City of EI Segundo ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street EI Segundo, CA 90245 AUTHORIZED REPRESENTATIVE (SMS ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Printed by SMS on November 10,2017 at 02:50PM COMMERCIAL GENERAL LIABILITY CG 20 26 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION Policy Number: SRPGP-101-0717 Insured: Elite Special Events, Inc This•endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE ....._.................. ......................................................................... . Name Of Additional Insured Person(s)Or Organization(s) City of EI Segundo, its officers, officials, employees and volunteers 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 © ISO Properties, Inc.,2004 Page 1 of 1 DATE(MM/DDIYYYY) AC�3/�II� CERTIFICATE OF LIABILITY INSURANCE 1' I 11/13/2017 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(ies)must have ADDITIONAL INSURED provisions or 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 CONYAG'I NAME: Dave Warren Nielsen McAnan Insurance Services,Inc, PnHONEio,Extl: FAX No): (805)204-4501 y ADDREss': (805 379-8801................................ 4165 E,Thousand Oaks BlvdIAIL .m.--........._......__..__...........____...... Suite 325 INSURER(S) AFFORDING COVERAGE NAIC# Westlake Village CA 91362 I wsuRERA: California Auto Insurance 38342 INSURED INSURER B ELITE SPECIAL EVENTS,Inc INSURER C: 404 N Sparks St _......__........_.............. .----.--.......................................� INSURER D INSURER E': Burbank CA 91506-1963 I INSURER F: COVERAGES CERTIFICATE NUMBER: CL1782304288 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 POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, .. F INSURANCE I,NS W1/O .........,�................_POLICY NUMBER ...............................-..,.,(MMIDD/YYYY) MMIDD/VE,X�,.l ....,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.... ...... INS'R L SU13Vf Pp" LTR TYPE O yyy LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ ............................ _�i7f"FAti'0�'"717 KtiE"K�tU CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ .................................................................................. MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ OTHER:❑ PRO. LOC ..R. ...................a_......,.,.......,.,.,.,.,...... POLICY PRODUCTS-COMP/OP AGG $ ,.,.,.....�.... .,....,�.,�................r............................................. ..........�.. AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT s 1,000,000 F_a accident W,..,., ..�.,.,�, -�.,....,m..l�...l............................................................. ANY AUTO BODILY INJURY(Per person) $ ., ."'..............................................................._� A OWNED SCHEDULED BA040000023533 08/31/2017 08/3112018 BODILY INJURY(Per accident) 5 AUTOS ONLY AUTOS HIRED AUTOS ONLY AUTOS ONLYf? aa alldlhMl§4'r&'�!; aonl:aa m,' dsaaoua EACH OCCURRENCE EXCE UMBRELLA LIAR $ OLAIMS MADE AGGRE SS LIAR GATE $ AND EMPLOYER .COMPENSATION ABILY I N WORKERS .ITY .,w.....__ .,�m....................................................... ....,...,.1.,,STATUTE.... 5 DED RETENTION 5 �,._......�L.. ............... _ ....,........ ....... ............................ rH- R ANY PROPRIETOR/PARTNERIEXECUTIVE DENT $ OFFICER/MEMBER EXCLUDED? NIA ^EL DSEASECIE Mandator in NH A EMPLOYEE 5 If yes,describe under �............................................................... ,,,,,,,,,,,,,,,,,,,,,,,,,,, DISEASE-POLICY LIMIT 5 .................. 5 below ...........L.................................................................. E� .......................................... DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may attached if more space is required) City of EI Segundo,its officers,officials,employees and volunteers are listed as additional insureds per attached MCA-85100817-CA Event Date 12/02/2017 Event Location:Library Park-EI Segundo CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN City of EI Segundo ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street AUTHORIZED REPRESENTATIVE EI Segundo CA 90245 I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ..14" MERCURY Business Auto Broadening Endorsement Provide superior coverage by adding this endorsement! This is a brief description of the coverage enhancements.See the actual endorsement for more specdics about coverage and conditions. Newly Acquired or Formed Entity (Broad Form Named Insured) —Adds, as an insured, any newly acquired or formed entity provided the insured owns at least 50% of that entity and it is formed V during the policy period. The maximum period is 180 days. Primary and Non-Contributory if Required by Contract—We will not seek contribution from any other insurance available under specific conditions. Employees as Insureds—An employee becomes an insured while using a covered auto that the insured does not own, hire or borrow. Automatic Additional Insured —Any person or organization that the insured is required to include as an additional insured based on a contract or agreement that is executed prior to the injury or damage. Employee Hired Auto—An employee is an insured when operating an auto that is hired or rented in the employee's name while on company business. Supplementary Payments— Bail bonds coverage is increased to $3,000. Reasonable expenses and loss of earnings, up to $500 per day, incurred by the insured are covered. Fellow Employee Coverage—The exclusion has been removed. Additional Transportation Expense—We will pay up to $50 per day, maximum is $1,000, for temporary transportation expense resulting from the total theft of a covered auto. Hired Auto Physical Damage Coverage— If you have Hired Auto Liability coverage, and you carry physical damage coverage for any of your autos, we will extend coverage for Hired Auto Physical Damage to a limit of$50,000, subject to a $500 deductible. Accidental Airbag Deployment—We removed the exclusion, providing coverage for airbag deployment that is accidental. Loan/Lease Gap— Coverage for the unpaid amount due on the lease or loan has been added if there is a total loss of an auto insured under this policy. Glass Repair— Deductible Waiver—We will waive the deductible if glass is repaired rather than replaced. Two or More Deductibles— If two or more policies or coverage forms from the company apply to the same accident, only one deductible will be applied. Amended Duties in the Event of Accident, Claim, Suit or Loss—The insured must notify us of an accident as soon as possible. Waiver of Subrogation —We waive our right of recovery against others if the insured has executed a written agreement prior to the accident or loss. Unintentional Error, Omission, or Failure to Disclose Hazards—The policy will not be deemed invalid if the insured unintentionally omits, errs or fails to disclose a hazard. Employee Hired Auto - If the employee hires or rents a vehicle with permission of the insured, Hired Auto Physical Damage applies. Hired Auto—Coverage Territory—Coverage applies anywhere in the world if an auto is leased, hired, rented or borrowed without a driver for a period of 30 days or less, and the insured's responsibility to pay for damages is determined in a suit brought in the US, its territories and possessions, Puerto Rico, Canada or in a settlement that we agree to. Bodily Injury Redefined to Include Resultant Mental Anguish — Bodily Injury includes mental anguish. CA,AZ,TX,OK,GA 10-16 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. (_J I have and will maintain workers'compensation insurance as required by Labor Code§3700 forthe 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# W 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 shouldbecome subject to the workers' compensation provisions of Labor Code § 3700 1 must immediately comply with those provisions or the agreement will automatically become void. Signature of Applicant Date S—IY-/7 w , Agreement for: Dated: Reviewed by: 1