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PROOF OF INSURANCE (2018 - 2019) CLOSED AC+G;Z Id CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 11,..i �,1 ' (E 5/9/2018 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 CONTACT Stephanie Weiss Specialty Insurance Agency PHONE FAX Performers of the U.S. (AIC Nod f�)hcerts s ec a0181nsurancea enc co IAIc No). 715-246-4257 P.O. Box 24 a DORS. s: @ P tY 9 Y• ..„ New Richmond,WI 54017 INSURER(S)AFFORDING COVERAGE NAICa INSURERA: Evanston Insurance Company 35378 INSURED Eric R.Greenberg INSURER B: dba Liberty City 18560 Vanowen St,Unit 14 INSURER c Reseda,CA 91335 INSURER D, 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 'OLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS YLNBRR ANSDD SWUVD POLICY NUMBER IMMIDDY EFF/WYY1 !MM pD TYPE OF INSURANCE POLICY EXP ryyyyY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,OOo DAMAGE 1'0 PEW ED �$ 300,000 CLAIMS-MADE AX OCCUR PREMISES(Ea occurrencce} MED EXP(Any one person) S 5,000 A X X 2CN0162-2490 04/25/2018 04/24/2019 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE S 2,000,000 X POLICY I]Ro• LOC PRODUCTS $ ,J000,000 AUTOMOBILE LIABILITY CM,:IMBINED SINf,`r1,E LIM0 $ (Earacr„idrrtl ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per ac AUTOS ONLY AUTOSHIRED NON-OWND accident) $ AUTOS ONLY AUTOS ONLYY (Pei accideD $ 4,,)PER1'”! AMAGE,,, „ ., $ UMBRELLALIAB r I OCCUR EACH 0 �$ EXCESS LIAB ,I CLAIMS-MADE AGOPEGAWE COCCURRENCE $ Y DED , 1 RETENTIONS V$ WORKERS COMPENSATIONPER 01H AND EMPLOYERS'LIABILITY Y/N „II„STATUTE I, ER ANYPROPRIETOR/PARTNER/EXECUTIVE E ,EACH ACCIDENT $ OFFICE1 L (Mandatory in NH) EXCLUDED d NIA E L,r;8 SEAASE'•E,A,EMPl,f,',�'YE E $ (Mandatory in NH) If yes,describe under DESCRIPTION OF OPERATIONS below E L DISEASE P0I,,I(';Y LliyiI11 $ A BUSINESS PERSONAL PROPERTY• AGGREGATE $ INLAND MARINE DESCRIPTION OF OPERATIONS/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:TheThe 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:May 19,2018 CERTIFICATE HOLDER CANCELLATION City of EI Segundo 350 Main Street,Room 5 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE E(Segundo,CA 90245-3813 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE I @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 2CN0162-2490 COMMERCIAL GENERAL LIABILITY CG 20 01 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CE COMDITIOI 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 CG 20 01 0413 ©Insurance Services Office, Inc., 2012 Page 1 of 1 POLICY NUMBER: 2CN0162-2490 COMMERCIAL GENERAL LIABILITY CG 20 12 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURE - STATE OR GOVERNMENTAL AGENCY OR SUBDIVISION OR POLITICAL SUBDIVISION - PERMITS OR AUTHORIZATIONS S This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE State Or Governmental Agency Or Subdivision Or Political Subdivision: I City of EI Segundo City Clerk Attn: Recreation & Parks Director 350 Main Street, Room 5 EI Segundo, CA 90245-3813 The City of EI Segundo, its officers, officials, employees, agents and certified. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to 2. This insurance does not apply to: include as an additional insured any state or a. "Bodily injury", "property damage" or governmental agency or subdivision or political "personal and advertising injury" arising out subdivision shown in the Schedule, subject to the of operations performed for the federal following provisions: government, state or municipality; or 1. This insurance applies only with respect to b. "Bodily injury" or "property damage" operations performed by you or on your behalf included within the "products-completed for which the state or governmental agency or operations hazard". subdivision or political subdivision has issued a permit or authorization. B. With respect to the insurance afforded to these additional insureds, the following is added to However: Section III— Limits Of Insurance: a. The insurance afforded to such additional If coverage provided to the additional insured is insured only applies to the extent permitted required by a contract or agreement, the most we by law; and will pay on behalf of the additional insured is the b. If coverage provided to the additional amount of insurance: insured is required by a contract or 1. Required by the contract or agreement; or agreement, the insurance afforded to such additional insured will not be broader than 2. Available under the applicable Limits of that which you are required by the contract Insurance shown in the Declarations; or agreement to provide for such additional whichever is less. insured. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. CG 20 12 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1 COMMERCIAL GENERAL LIABILITY POLICY NUMBER: III 2CN0162-2490 EVA STON 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: III 2CN0162-2490 MARKED 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.®) 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 0009-0104 11 Includes copyrighted material of Insurance Services Office, Inc. Page 1 of 1 with its permission. P000000407/C000018922.0071038-'VIP-AD0487 /SEL/3 PERSONAL AUTOMOBILE Offer To Renew Declaration effective POLICY DECLARATION May 5,2018 ' Insurance Your coverage expires May 05,2018,at 12:01 A.M. Payment of the premium renews your policy for the period shown.If your payment is not reaelved before May 05,2018 this Offer to Renew will be null and void. NAMED INSURED AND ADDRESS SERVICE OFFICE 9`2 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 May 5,2018 to Nov 5,2018 Named Insured as stated herein Named Insured's Phone Number:818-344-8332 Named Insured's Email Address:info@libertycityent.com Your 6 month premium for two(2)vehicle(s)is$1,369.32. Refer to the breakdown of premiums below. Description of Owned Vehicle(s) Vehicle I Year Make Model Vehicle Identification Number Premium per Vehicle($) 1 2009 Honda FIT JHMGES82298059233 532.94 2 2013 Hyundai ELANTRAGLS/ELANTRA KMHDH4AE4DU952103 �_ 836.38 LIMITED .............. Premium Subtotal for Vehicles 1369.32 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(5) See Policy for Coverage DetailsI 1 2 Bodily Injury Liability $15,000 per person/$30,000 each occurrence 153.56 241.18 Property Damage Llablllty $5,000 each occurrence 108.75 186.11 Medical Payments $5,000 each person 27.92 40.61 Comprehensive $500 deductible 21.83 21.82 Collision $500 deductible 183.71 293.31 Uninsured/Underinsured Motorists Protection $30,000 per pareon/$60,000 each occurrence 35.42 51.60 Uninsured Motorists Collision Deductible Waiver 1.75 1.75 Total Premium per Vehicle(S) 332.94 836.38 All premiums listed are for the full 6 month term. Apr 04,201800:45 CT "Wawanesa Insurance"Is a trademark of Wawanesa General Insurance Company EnWainmerd to Event l d Wholesale C TY May 9, 2018 To Whom It May Concern, Liberty City contracts our various performers on an "as needed" basis for individual events rather than hiring individuals as employees. All of the performers are independent contractors responsible for their own taxes. Since we have no employees we do not provide workman's compensation. If in the future I hire employees, I will obtain worker's compensation and notify . Sincerely, Eric Greenberg 18560 Vanowen St. #14 • Reseda, CA 91335 • office: 818-344-6929 • fax: 818-344-6108 w w w . I i b e r t y c i t y e n t . c o m