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PROOF OF INSURANCE (2018 - 2018) CLOSED AC<?RV CERTIFICATE OF LIABILITY INSURA CEDATE(MM/DD/YYYY) 04/12/2018 PRODUCER THIS CERTIFICATION IS ISSUED AS A MA'T'TER 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 Crown Five, LLC&Kelly Rae Band INSURER B: Kelly Roemer 1639 Calle Las Bolas Unit-B INSURERC. San Clemente,CA 92672 INSURER D: INSURERE:,, 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, 'INSR ADDTI POLICY EFFECTIVE LTR INSRD TYPE OF INSURANCE I POLICY EXPIRATION' POLICY NUMBER DATE(MM/DD/YY) I DATE(MMIDD/YY) LIMITS GENERAL LIABILITY j EACH OCCURRENCEINcwDES $ 1,000,000 A Y X COMMERCIAL IGENERAL LIABILITY BODILY INJURY&PROPERY DAMAGE bN )I „ MED EXP(Any one person)� Puyll D $ 5,000 CLAMSMAEXOCCUR PERSONAL&ADV INJURY $ 1,000,000 Host Liquor Liability GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000 X POLICY PRO- JECT LOC DEDUCTIBLE $ 1,000 Retail Liquor Liability $ AU`OMOBILE 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 LIABILITYAUTO ONLY-EA ACCIDENT $ O. .. ANY AUTO OTHER THAN EA ACC $ AUTO ONLY AGG $ xCESS/UMBRELLA LIABILITY OCCURRENCE $ .... E OCCUR ( CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ WORKERS COMPENSATION AND WC STATU- OT'H- EMPLOYERS'LIABILITY TORY LIMIE L EACH ACCT j I ER $ ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? E L DISEASE-EA EMPLOYEE $ If yes,describe under SPECIAL PROVISIONS below E L DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS/ /VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Certificate holder listed below is named as additional insured per attached CG 20 26 07 04. Attendance:5000,Event Type:Performer at Event CERTIFICATE HOLDER CANCELLATION', City of EI Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION it's officers,Officials,employees DATE THEREOF,THE ISSUING INSURER WILL fiMK- :MAIL 30 DAYS WRITTEN agents and volunteers 401 Sheldon St. NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, EI Segundo,CA 90245 IMPOSE Its BOMB AUTHORIZED REPRESENTATIVE ✓ ACORD 5(2001108) C ACORD CORPORATION 1988 Policy Number: 3DS5466-M1740458 COMMERCIAL GENERAL LIABILITY CG 20 26 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL AL 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 EI Segundo it's officers,officials,employees agents and volunteers 401 Sheldon St. 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 13 iL 111 FOLD TOP AND BOTTOMOF CARD ON PERFORATION STATE Sta�b I,� '� ,111111 I I Iuluulupig, teary UIFORNIA hI� �'luuu li I II IIVuIII�uuIhI��IIIIIJIO�'llll'llll0°d^IYIIIIvA� �� ry'�Ild 1 I I IhI �IV I,p Vgh4uuVlli� M1Vy� I�i, i�lll 4� IIIIIIIIIII�II�I II IIIIIIIIII°1 j111�A �ullll ° ,IlpilillV ill IIIVI I�Nml�i��l��lllrl 11 I .iilll w INSURANCE, CARD r IIV'lllll1��'li'I�II �wl��ww� �� q N VIII 1111111 muuuuuuuuuuuu uuuum State IIII191ulyI��IIVI�'fl II�I��hoIR I ISP iu111,I �I I Farm ll Automobile Insurance uiII II�dV l lil,ll 1111 !pl PO Box 853922 ' IIIIIIIIIII Illhi�li I1^tied Ipl Richardson, TX 750 IIIIIYIIII�,IIII1�iIIYIi+ 1; "rN �141A ill�� ' III Illlu ippu' `I INSURED , Ji Ji ill�jiiill�ll��ll4ulilllllll!��u l II +Iklll��lillp�'!PIII�;��;'j1��1�I I;dy�ll�"„` IIIIIII�� „I,I, III � II�II Illl(l`u�ii�l Illlilu�IIl��Ih���IIuwNd I,I ��I wl'iollulll IIIVINVI'Y((�fl'YIY I�A�Ill�l�lil''i lllll����N'V' I !,IuiIlll�iiii�II�IIrIIPIio�”plhl��pj���ll�`I"I'IiIJIj4�IVIjIMP^Ihlii1111111�1��1 �e POLICY NUMBER025 7526-D13-76Q :: ,h1J�I;44�y�fl" II�I�lll�>III II U lu��n ulllllhlp��1ll�l w �rrri I, Ii���Il IIS II uu YR 2014 MAKE TOYOTA, MODEL FJ CRU�ISERI" AGENT DIANE PHONE �714�5294551$ P',III,I I, I,, 111111 CO IP "I ED BY THE;,,, X11 PRESCRIBED w C01�EI00 G II hI Illi llllll ll�Ill�uu illlll �IIIIIIIIIIII _, Ini fIIIINII �I � I EE Ilu ' µ1111h11 uIIIPIvil , I IlumiIII^11��u���1111�"�I�u1'l nImYu�llllllllllllluuuuuuuuuu�liiiilulluu. w 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: (_J 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. (_) 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 El Segundo is executed. My workers' compensation insurance carrier and policy number are: Carrier Policy Number Expiration Date Name of Agent Phone# (j-} 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 should become subject to the workers" compensation provisions of Labor Code § 3700 1 must immediately comply with tho 'sions or th ag . rt "fI automaticalfy me void. �" Signature of Applicant Daae Print Name Agreement for: Dated: Reviewed by: ".: