PROOF OF INSURANCE (2018) CLOSED AC R � CERTIFICATE O ' LIA ILI°T I S ' C I °"0412' 312018
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: It the certi'f'icate holder Is an ADDITIONAL.INSURED,the pollc'y(les)must.be endorsed.d. 11 U8R6G "nON IS WAIVED,sull)oot to
the terms and conditions of the policy,Certain policies may require an endorswnenL A statement on this certificate does not confer rights to the
certificate holder In lieu of such endorsement(s).
PRODUCER &;ON I Act
EIAM�:
HCC Specialty p
PHONE E AMC'May.
401 Edgewater Place,Suite 400 ADDRESS:
WODUCER
Wakefield,MA 01880 '7 " --- --
INSURER(S)AFFORDING COVERAGE NAIC i
INSURED NSURERA: New HampshireInsurance Company— 23841
Main Street Band NSURERB: United States Fire Insurance Company 21113
406 Maryland St. NSURERC:
EI Segundo,CA 90245 V INSURER D:
INSURER E:
INSURER F:
COVERAGE a 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.
ILTRR TYPEOFINSURANCE IINSR SWVD POLICYNUMBER (IOM DDYYyYI INMI pIEYSYNYI LIMITS
GENERAL LIABILITY EACH OCCURRENCE s 1.000,000 I
A X SEL013692127 04/25/2018 07/07/2018 � TcpT)y ' --
X CDMMERCIALGENERALL/ABILITY g 300,000...,
t'Lt.1lltiSd1a1
CLAIMS-MADE OCCUR I„� �f?' :0dw._._ S 5,QO0
Host LilquorPERSONAL9AOVINJURY $
1,000,000
B '), Medical Expense US970171 04/25/2018 107/07/2018 GENERAL AGGREGATE000, 00
�s 2, 0
�GEN'LAGGREGATE LIMIT APPLIES� PER: I PRODUCTS-COMP/OPAM�f 1,000,0W
XII POLICY�JET F-1 I LOC I f
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT f
(Ea aoddent)
ANY AUTO
BODILY INJURY(Par person) f
ALL OWNED AUTOS
SCHEDULED AUTOSBODILY INJURY(Per acoidera) s
PROPERTY HIRED AUTOS ' (Pr aCddenl)DAMAGE f
N014-OWNED AUTOS ( is
UMBRELLA LIAR OCCUR EACH OCCURRENCE pI S
EXCESS UAB HCLAIMS-MADE I AGGREGATE p f
DEDUCTIBLE f
RETENTION S S
WORKERS COMPENSATION
AND EMPLOYERS'LIABILITY ER
YIN
ANY PROPRIETORIPARTNERIEJ(ECUTIVE❑ E.L.EACH ACCIDENT f
OFFICER/MEMBER EXCWDED7
(Mandatory In NH) E.L.DISEASE-FA EMPLOYEE S
Vyas,0esarfe under
OESCRIPT ION OF OPERATIONS below EJ-DISEASE-POLICY LIMIT.S
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,AdMonal RemaAaSchadu1%Il mom epaoe Is required)
The CsrldiwU Helder Is added as Ad60anal Innned%ft respects to our Inarees opendim onyx.
This knower ispdrmryand nonzomMu”as"bmd by w fflm ores,
his oovrepe Is vft respect to Cay of Q 8"Undo 401 of July Celebration ewrrrt to be held 07/01=8-
07/01=1e at Recreation Park 19 8epundo CA
CERTIFICATE HOLDER CANCELLATION
City of EI Segundo,its Officers,officals,employees,agents,and SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANICELLED
BEFORE THE EXPIRATION DATE THEREOF.NOTICE WILL BE DELIVERED
Volunteers IN ACCORDANCE WITH THE POLICY PROVISIONS.
350 Main St
EI Segundo,CA 90245 AUT1tOR1z)®REPRESENTAT E .
1.
ACORD 25(201 W05) ®1988.2010 ACORD CORPORATION.All rights reserved.
POLICY NUMBER:13692127 COMMERCIAL GENERAL LIABILITY
CG 20 26 0413
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL I - DESIGNATED
ORGANIZATIONPERSON OR
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Persons)Or Organization(s):
As submitted to company and required by written contract.
II
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 B. With respect to the insurance afforded to these
include as an additional insured the person(s) or additional insureds, the following is added to
organization(s) shown in the Schedule, but only $action III—Limits Of Insurance:
with respect to liability for"bodily injury", "property If coverage provided to the additional insured is
damage or personal and advertising injuryrequired by a contract or agreement, the most we
caused, in whole or in part, by your acts or will pay on behalf of the additional insured is the
omissions or the acts or omissions of those acting amount of insurance:
on your behalf. �1. Required by the contract or agreement;or
1. In the performance of your ongoing operations; 2. Available under the applicable Limits of
2. In connection with your premises owned by or '
Insurance shown in the Declarations;
rented to you. whichever is less.
However: 'This endorsement shall not increase the
1. The insurance afforded to such additional applicable Limits of Insurance shown in the
insured only applies to the extent petted by Declarations.
permitted
law;and
2. If coverage provided to the additional insured is
required by a contract or agreement, the
insurance afforded to such additional insured
will not be broader than that which you are
required by the contract or agreement to
provide for such additional insured.
CG 20 26 0413 0 Insurance Services Office, Inc.,2012 Page 1 of 1
POLICY NUMBER: 13692127 COMMERCIAL GENERAL LIABILITY
CG 20 11110413
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONALS
LESSORS
This endorsement modes insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Designation Of Premises(Part Leased To You):
City of EI Segundo, its officers,officials, employees,agents,and volunteers 350 Main St EI Segundo CA 90245
Name Of Person(s)Or Organization(s)(Additional Insured):
City of EI Segundo, its officers, officials, employees,agents, and volunteers 350 Main St. EI Segundo CA 90245
Additional Premium: Included
Information required to complete this Schedule, if not shown above,will be shown in the Declarations.
A. Section 11 —Who Is An Insured is amended to 2. If coverage provided to the additional insured
include as an additional insured the person(s) or is required by a contract or agreement, the
organization(s) shown in the Schedule, but only insurance afforded to such additional insured
with respect to liability arising out of the will not be broader than that which you are
ownership, maintenance or use of that part of the required by the contract or agreement to
premises leased to you and shown in the provide for such additional insured.
Schedule and subject to the following additional B. With respect to the insurance afforded to these
exclusions: additional insureds, the following is added to
This insurance does not apply to: Section III—Limits Of Insurance:
1. Any'occurrence"which takes place after you If coverage provided to the additional insured is
cease to be a tenant in that premises. required by a contract or agreement,the most we
2. Structural alterations, new construction or will pay on behalf of the additional insured is the
demolition operations performed by or on amount of insurance:
behalf of the person(s) or organization(s) 1. Required by the contract or agreement; or
shown in the Schedule. 2. Available under the applicable Limits of
However. Insurance shown in the Declarations;
1. The insurance afforded to such additional whichever is less.
insured only applies to the extent permitted This endorsement shall not increase the
by law;and applicable Limits of Insurance shown in the
Declarations.
CG 20 110413 0 Insurance Services Office, Inc.,2012 Page 1 of 1
Main Street
(Vintage Band)
Date: 4-21-18
TO: City of EI Segundo
Re: Business Automobile Liability Insurance and Worker's Comp
I, Jean-Louis Boudreau,band member of Main Street Band,certify that all band members are
independent contractors.
The band is not incorporated and does not carry Business Automobile Liability Insurance.
Thank you,
,dean- o 'is Boudreau
406 Maryland Street * EI Segundo - CA 90245 o tel: 310.720.9360 * fax: 310.726.0138
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.
U 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#
4e1 certify that, in the performance of the work set forth in the agreement with the City of EI Segundo, I will not
ploy any person in any manner so as to become subject to the workers' compensation laws of California, and
e that, if I should became subject to the workers' compensation provisions of Labor Code § 3700 1 must
9 pp p ns or the agreement will automatically become void.
Signature of Applicant cant o rout o
immediately comply with Date 6
Print Name
Agreement for:
NA-
Dated:Dated:
Reviewed b 4