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PROOF OF INSURANCE (2018) CLOSED ZEBRA-1 OP ID:JJ CERTIFICATE OF LIABILITY INSURANCE � DATE(M11/2712017 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 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 NAMEiCONTACT Dick Wardlow Ins Brokers Dick Wardlow 001nsurance Brokers PHONE 05-553- d05 FAX rip); 805-553-0606 233 High Street C•MAIL ma owinsurance.com Moor ark,CA 83021 ADDRESS .. . ,.. . ,,, 1 RAGE NAIC# Dick ardlOww Ins Brokers INSURER S)AFFORDING COVE IEvanston Insurance Company INSURED Zebra En __ _ INSURER Mzer 11024 ll Balboa Entertainment and Events INSURER B: tertai Blvd#118 INSURERC: INSURER E Granada Hills CA 91344 INSURER R 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 ILTR TYPE OF INSURANCE 'NDS p POLICY NUMBER IMMIDDIIYEYYY) fMMID W EMP LIMITS LI Y EXP N GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 AMAGERENTED A X COMMERCIAL GENERAL LIABILITY X 3DS5455-M1642654 02/06/2017 02/06/2018 PREMISESO(Ea oixmtrenica) $, 100,000 CLAIMS-MADE X„I OCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEMLAGGREGATELIMITAPPLIESPER: PRODUCTS-COMP/OPAGG $ 1,000,000 J�IROI I X1 POLICY I I Loc Deduct- $ 1,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ ANY AUTO ® BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED OE.RT D,A�A" HIREDAUTO5 (PP � fC $ $ UMBRE A EXCESS LAB I CLAIMS-MADE XOBW7061117 11/11/2017 11/12/2017 AGGREGATEOCCURRENCE $ 4,000,000 EXCESS LIAB OCCUR EACH OCCIR $ 4,000,000 X ., X DED ( RETENTION$ $ WORKERS COMPENSATION WC STACU- OTH- AND EMPLOYERS'LIABILITY ...._ITQ,R,Y J.WITS I ER ANY OFFICER/MEMBER MEMB HR EXCLUDED?ECUTIVE "I N NIA E L EACHACCIDENT $ (Mandatory ) E L DISE EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) The City of E1 Segundo, its officers, officials, employees, agents and volunteers are named as Add'1 Insureds, but only insofar as the operations under this Written Contract are concerned. This Policy is Primary & Non- Contributory. All Event Dates. CERTIFICATE HOLDER CANCELLATION CO-ES00 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of EI Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street EI Segundo,CA 90245 AUTHORIZED REPRESENTATIVE n ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Policy Number: 3DS5455-Ml 642654 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) City of El Segundo, its officers, officials,employees,agents& volunteers 350 Main Street El Segundo,CA 90245 Information required to complete this Schedule,if not shown above,will be shown in the Declarations Section 11 — Who Is An insured is amended to inn clude as an additional insured the person(s)or organi- zation(s)shown in the Schedule, but only wf1h respect to liability for "bodily injury", "property darnage" or °"personal and advertising injury" caused, in whole or in part, by your acts or ornissions 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 ❑ Jan 19 18 12:21 p Zebra Entertainment 8 Ev 8183047558 p,4 AW 05-M 0 111116111111111111 i-5F& ExAlzrtainmeat umdEv ats January 19,2016 City of EI Segundo-Recreation and Parks Monse Palacios 401 Sheldon Street EI Segundo,CA 90245 Regarding:All Event Dates-2016 Dear Me.Palecios, This confirms that Zebra Entertainment and Events does not own or rent any vehicles,and therefore does not cavy any Automobile Liability Insurance. We cannot cover vehicles privately owned by Independent Contractors, Our Insurance carrier does not offer coverage for hired and non owned vehicles for our class of business. The operators we contract with are all Independent Contractors, and not employees,so therefore we are not required to carry any Worker's Compensation policy for them, according to the California Labor Code. Thank You, C��44 /11911k� Shelly Mazar,owner Zebra Entertainment and Events 11024 BalboaW Suft 113 Granad►aflllla Cel#ornla 91344 818.368.1818 wmv,Ze6rol�r�rraln nbindElenti corn Dec 0417 05:48p Zebra Entertainment&Ev 8183047558 p.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 Ind ustrjW Relations as provided for by Labor Code§3700 for the performance of the work set-forth the agreement with the City of El Segundo. Policy No. I gave 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 El Segundo is executed. My workers' compensation insurance carrier and policy number are: Carrier Policy Number Expiration Date Name of Agent Phone4 I certify 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 workers' compensation provisions of Labor Code q 3700 li must immediately comply with those i )ns t e eement will automatically become void. _pl��C, <., Signature of fi 71/1)Tel-, Date Print Name Agreement for: Dated- Reviewed by,