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PROOF OF INSURANCE (2018 - 2018) CLOSED INA ^��• DATE(MMIDDIYYYY) !"1k��k,.J',.�7wAr.,✓ CERTIFICATE OF LIABILITY INSURANCE I 3/30/2017 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 CONI CT Stephanie Weiss Specialty Performers of the U.S.surance gency (At Nop Ml. 715-246-8908 d.C��a.No 715 246-42 t 57 P.O.Box 24 A,o"D�x SSS certs@specialtyinsuranceagency.com New Richmond,Wl 54017 INSURERISIAFFORDING COVERAGENAIC# INSURER A: Evanston Insurance Company 35378 INSURED Eric R.Greenberg INSURER B dbaLiberty City INSU.R.ER.c....................................................................... ....-_... 18560 Vanowen St,Unit 14 Reseda, CA 91335 iNsuRERD: 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 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. LTR "I'll�.. ...... ....... tiL""�fl.it@�� POLICY...,. LIMITS.. ... . ......, �.. ..-.. E� POLICY EXP ITR TYPE OF INSURANCE Wisp wvn POLICY NUMBER imm/nnIYYYVi (MMIDDIYYYYI_ - X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAC t5 TO FfEN"ED CLAIMS-MADE X OCCUR PREMISES,Fit as Cna!yt rqj S 300,000 MED EXP(Any one person) S 5,000 .. A X X 2CN0155-2490 04/25/2017 04/24/2018 PERSONAL SADV INJURY $ 1,000,0,00m GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X .I OIIIrR, JECr LOC PRODUCTS $ .2..........0,0..._ .. 000 00 AUTOMOBILE LIABILITY COMBINE(Fa accden,t)SIN(tLP t.Wt,iIP .. $ .. Y.... ..............................i ANY AUTO BODILY INJURY(Per person) S . OWNED ....-., SCHEDULED .BODILY.......................(Per a......c.C1dent) $ „._�.,.,..._,...-...�. .....,»_.,...,.. AUTOS ONLY ,,,,�, AUTOS t) HIRED NON-OWNED .µF4C9F"t.P'2N`i'i' N.A&hl:,F;. ........' .......�'�._--..�� . .'W.... AUTOS ONLY AUTOS ONLY $ `gym, UMBRELLA LIARCCUR RENCE $ m-_ EXCESS LIAB CLAIMS MADE AGGREGATE , $ UM DI=D RETENTION$ $ !WORKERS COMPENSATION wEH V OI H- AND EMPLOYERS'LIABILITY YIN � J,. (Mandatory MBER EXCLUANYPROPRIETOR/PARTNEDED? /EXECUTIVE ❑ E,L EACH ACCIDENT $ .,. NH) (Mandatory In ER EXCLUDED? N I L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ A BUSINESS PERSONAL PROPERTY AGGREGATE $ INLAND MARINE DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) PERFORMER IS A NAMED INSURED AS A MEMBER OF PERFORMERS OF THE U.S.: Eric R.Greenberg dba Liberty City Additional Insured:The City of EI Segundo,its officers,officials,employees,agents and certified volunteers are named as additional insured,but only insofar as the operations under this contract are concerned. Fax:818-344-6108 Email:libertycityeric@aol.com Event Date:2017-06-11 ,a CERTIFICATE HOLDER CANCELLATION City of EI Segundo 350 Main St,Room 5 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE EI Segundo,CA 90245-3813 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE A L^--•- I A '_- __, ©1988-2015 ACORD CORPORATION. All rights reserved, ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD POLICY NUMBER; 2CN0155-2490 COMMERCIAL GENERAL LIABILITY CG 20 01 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance (2) You have agreed in writing in a contract or Condition and supersedes any provision to the agreement that this insurance would be contrary: primary and would not seek contribution Primary And Noncontributory Insurance from any other insurance available to the This insurance is primary to and will not seek additional insured. contribution from any other insurance available to an additional insured under your policy provided that: (1) The additional insured is a Named Insured under such other insurance; and '41L CG 20 01 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1 COMMERCIAL GENERAL LIABILITY POLICY NUMBER: gig 2CN0155-2490 MARKEr EVANSTON INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET WAIVER OF SUBROGATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM SCHEDULE Additional Premium: $0 Name of Person or Organization: Any person(s)or organization(s)to whom the Named Insured agrees to waive rights of recovery in a written contract. The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV — COMMERCIAL GENERAL LIABILITY CONDITIONS) is amended by the addition of the following: We waive any right of recovery we may have against the person or organization shown in the Schedule above as respects written contracts that exist between you and such person or entity, provided you have agreed in writing to furnish this waiver. This waiver applies only to the person or organization shown in the Schedule above. All other terms and conditions remain unchanged. MEGL 0241-01 04 11 Includes copyrighted material of Insurance Services Office, Inc. with its Page 1 of 1 permission. COMMERCIAL GENERAL LIABILITY POLICY NUMBER: 2CN0155-2490 MARKSV EVANSTON INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED This endorsement modifies insurance provided under the following COMMERCIAL GENERAL LIABILITY COVERAGE FORM PRODUCTS/COMPLETED OPERATIONS COVERAGE FORM LIQUOR LIABILITY COVERAGE FORM PROFESSIONAL LIABILITY COVERAGE FORM Please refer to each coverage form to determine which terms are defined. Words shown in quotations on this endorse- ment may or may not be defined in all coverage forms. SCHEDULE Person or Entity: Any person or organization to whom you are obligated by valid written contract to provide such coverage. Additional Premium: $ (Check box if fully earned.E) Included WHO IS AN INSURED is amended to include the person or entity shown in the Schedule above as an Additional Insured under this insurance, but only as respects negligent acts or omissions of the Named Insured and only as respects any coverage not otherwise excluded in the policy. Our agreement to accept an Additional Insured provision in a contract is not an acceptance of any other provisions of the contract or the contract in total. When coverage does not apply for the Named Insured, no coverage or defense shall be afforded to the Additional In- sured. No coverage shall be afforded to the Additional Insured for injury or damage of any type to any "employee" of the Named Insured or to any obligation of the Additional Insured to indemnify another because of damages arising out of such injury or damage. All other terms and conditions remain unchanged„ MEGL 0009-01 04 11 Includes copyrighted material of Insurance Services Office, Inc. Page 1 of 1 with its permission. P000000503/C000023314.0071042-"VIP-A00593 /SEL/3 PERSONAL AUTOMOBILE Offer To Renew Declaration effective •. , POLICY DECLARATION Nov 5,2017 Your coverage expires Nov 05,2017, at 12:01 A.M. Payment Of the premium renews your policy for the period shown.If your payment is not received before Nov 05,2017 this Offer to Renew will be null and void. ERIC GREENBERG WAWANESA INSURANCE 18560 VANOWEN ST#14 9050 FRIARS RD STE 101 RESEDA CA 91335 SAN DIEGO CA 92108-5865 Telephone: 1-800-640-2920 Policy Number Account Number Policy Period 12:01 A.M.standard time at the address of the 11345100 2174251-1 From Nov 5,2017 to May 5,2018 Named Insured as stated herein Named Insured's Phone Number:818-344-8332 flamed Insured's Email Address: info@libertyc4ent.com Your 6 month premium for two(2)vehicle(s) is $1,535.69. Refer to the breakdown of premiums below" Description of Owned Vehicle(s) Vehicle Year Make Model Vehicle Identification Number Premium per Vehicle($) 1 2009 Honda FIT JHMGES82298059233 728.86 2 2013 Hyundai ELANTRA GLS/ELANTRA KMHDH4AE4DU952103 806.83 LIMITED Insurance Is provided only with respect to the coverage's for which a Premium Is stated, subject to all conditions of the policy. Coverage and Limits of Liability Premiums per Vehicle ($) See Policy for Coverage Details 1 2 Bodily Injury Liability $15,000 per person/$30,000 each occurrence 232.32 255.21 Property Damage Liability $5,000 each occurrence 125.84 157.06 Medical Payments $5,000 each person 49.82 54.16 Comprehensive $500 deductible 25.67 16,91 Collision $500 deductible 244.05 267.86 Uninsured/Underinsured Motorists Protection $30,000 per person/$60,000 each occurrence 49.85 54.32 Uninsured Motorists Collision Deductible Waiver 1.33 1.33 Total Premium per Vehicle($) 728.86 606.83 Oct 05,2017 00:31 CT "Wawanesa Insurance"is a trademark of Wawanesa General Insurance Company DRIVER UGENSE U201 1413, 0,4b NONE 14 q a tad"FE ERIC RALPH IONO YAMMER API 14 MEDA,CA 01335 Rll R OOM LENS 015071963 3EX m t(AAKL ORM ORR A-4, PIGY V-4w Volj)l 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 9elf4nsure 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# �6 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 prov s ort s orth greemen will automatipally become void. Signature of Applicant . 4 „ - /17 Date Print Name Agreement for: l Dated: r� Reviewed by: