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PROOF OF INSURANCE (2018 - 2019) CLOSED CERTIFICATE OF LIABILITY INSURANCE 1DATE IMMIDDNYYY) 05110/2018 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 certlficate 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 pollcy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement($), PRODUCER CONTACT ShelIPAppling �4 _www3 tl 3 _ Appling Insurance Services PHONE E■i): (562)594�B93 8aq Htalr (562)431-3685 10845 BLOOMFIELD STREET A MESS: Shellinapplinginsurance.net INSURER(S)AFFORDING COVERAGE I NAIC N LOS ALAMITOS CA 90720 UNI.................w.... NSURERA: TED SPECIALTY INSURANCE COMPANY N 12537 INSURED NSURERB: Hey Hey Entertainment,LLC,Richard Wolloski INSURER C: DBA:Hey Hey Entertainment INsuRERO: 3441 Faust Ave, NSURERE: Long Beach CA 90808 INSURER F: COVERAGES CERTIFICATE NUMBER: CL18420OB99 REV'ISI'ON 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. COMMERCIAL ArdN. SwV - ....,hOLICyEFr PdL18"yIEk1�"' TYPE OF INSURANCE INSID O NNO POLICY NUMBER LIMITS _ _ �MdDI�P'4°YYYI (pwVMrA7�DFY"b'1/'r'1-- " " ABILrrY EACH OCCURRENCE S 1,000,000 ..��CLAIMS-MADE OCCUR iUdWM1451L'd�.i a{tmry ital 100,000 Pr4Etl�lISESEo ocrtu�rvrerrc�o ._._ S MED EXP(Any one person) f 5,000 A Y USA4195090 0410912018 0410912019 PERSONAL B ADV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER � I GENERAL AGGREGATE f 2,000,000 POLICY JECTT LOC U PRODUCTS-COMP/OP AGG S 2,000 000 OTHER, .. ... ......., $ AUTOMOBILE LIABILITY . ... .. .,._„•. COMBIN"� N�"LE'_LId1'ItT f Ta acadent) ANY AUTO BODILY INJURY(Per person) $ I . OWNED I SCHEDULED AUTO5 ONLY AUTOS BODILY INJURY(Peraccdent) $ HIRED NON-OWNED PROPERTY OAMA(.4= f .—_ AUTOS ONLY AUTOS ONLY ..IPEL.a .de11.................................................................................................................. $ UMBREUMBRELLALIAR OCCUR EACH CLAIMS-MADE AGGREGATE °�. ETENTION S .__.. ..- �-... m..._........... ....... _ CRENGE I$ EXCESS ...._r..._ _....w WORKE SCOMPEkiiiii .............. .. AND EMPLOYERS'LIABILRY YIN _.1,,STATUTE I ERH- ANY PROPRIETORIPARTNERIEXECUTIVE " � NIA E L EACH ACCIDENT $ OFFICERJMEMBER EXCLUDED?(Msndabory In NH) E L DISEASE-Fri EMPLOYEE $ If yes,descnbe under DESCRIPTION OF OPERATIONS below E L INSEA„SE•POLICY LIMIT S DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be a@sched if more space Is required) ' THE CITY OF EL SEGUNDO ITS OFFICERS,OFFICIALS,EMPLOYEES,AGENTS&CERTIFIED VOLUNTEERS ARE HEREBY NAMED AS ADDITIONAL INSURED AS THEIR INTEREST MAY APPEAR IN THE OPERATIONS OF THE NAMED INSURED NTH RESPECTS TO LIABILITY 10 Day Notice of Cancellation for non-payment of premium CER'TIF'ICATE HOLDER CANCE'LLATI'ON SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN THE CITY OF EL SEGUNDO,PUBLIC LIBRARY ACCORDANCE WITH THE POLICY PROVISIONS. ATT'N LIBRARY DIRECTOR AUTHORIZED REPRESENTATIVE 111 W MARIPOSA AVE, u EL SEGUNDO CA 90245 ©1908-2015 ACORD CORPORATI N. 11 rights reserved. ACORD 26(2016103) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: USA 4195099 COMMERCIAL GENERAL LIABILITY CG 2010 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON O ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Omanization(s): Location(s)Of Covered Operations Any person or organization that you are required to All insured premises and operations add as an additional insured on this policy, under a written contract or agreement currently in effect, or becoming effective during the term of this policy. The additional insured status will not be afforded with re- spect to liability arising out of or related to your activi- ties as a real estate manager for that person or organ- ization. Information required to complete this Schedule, if not shown above,will be shown in the Declarations. A. Section It — 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 additional exctu- organization(s) shown in the Schedule, but only sions apply: with respect to liability for"bodily injury", "property This insurance does not apply to"bodily injury" or damage" or "personal and advertising injury" "property damage"occurring after: caused,in whole or in part,by: 1. Your acts or omissions; or 1. All work, including materials, parts or equip- ment furnished in connection with such work, 2. The acts or omissions of those acting on your on the project(other than service, maintenance behalf; or repairs) to be performed by or on behalf of in the performance of your ongoing operations for the additional insured(s) at the location of the the additional insured(s) at the location(s) desig- covered operations has been completed;or nated above. 2. That portion of "your work" out of which the injury or damage arises has been put to its in- tended use by any person or organization oth- er than another contractor or subcontractor engaged in performing operations for a prin- cipal as a part of the same project. THE CITY OF EL SEGUNDO, ITS OFFICERS, OFFICIALS, EMPLOYEES, AGENTS&CERTIFIED VOLUNTEERS CITY OF EL SEGUNDO PUBLIC LIBRARY 111 W. MARIPOSA AVE. EL SEGUNDO, CA 90245 CG 20 10 07 04 .©I 50 Properties, Inc., 2004 Page 1 of 1 O California Ial° VISI"IN, u' N, � IV II pPl Ii ly M V Auto . s"' HIc lVI4lIL fll M;IkIqqi Id x I IV VII mw"��• lr �IVpiudlmps„619 IIIWWyIwWwlllll ”" �� taWwWwW"'BW�wWMUIw" MfYM 'I�d�wlwr�xumm+A'www+w,xwmrvwMrv„rcm,.wMm,�,Mwmmmmmmmwm�uuwmwMmxumwrw;ww.wwww�wuuu.mmmnx��wx�wnwrr��� m°1 ip' PC ryu�'Y ;5�0'�� ���� II „V vI.N Mw N u v � � IIII�w'Iry P 0 E m" �,""'"NM wV Ix,^1, "I va ��oX^"�" IBulllp II M'���p i � l�? 11,E Y Uu � r� w 3441 Fowl Ave, Lan I' . 90808,2839 .l tI"v'; I,m",.a'!w'r', u,!A'I ��"d D';„°:�;t NIM'' there�v,�����Y��"I�,m �I�,I�^h,�,°."'�, II�Wm; ��the Nii�;�� Vr � w� I e �IIra��Iy ms h l SII Law(s) 111I ,VM ll ' I"I�!" W �, � MI � . �IIIY w�,I�I a I�uI, II �I I'll's u� ,��pl�' 11'4.iiy�l�I m',�II ','�W IIlIII"u�f����I Ilik!lll'I..M'm d'III w9'IY lie e ��m v,; �'��,�,p�'"��Iq°''�'�, Ia� t �u��ll''v t�'V��'"IR!'lol;l i "S m�'N"'� 1lll1!! w�'N v�;��'��,'" I,� ��II�� III!� 4 14 0s..10,AIA"a I�III� Illi���m u w IIII X"'" ..................._.... ... C1.T OF EL 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. (_) 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# N 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 -rage,ee-ftt-,-i"-should-becorr f--sti iect.....t,o.....t.he....workers" ermpensattor-t-pt°ov°d i n -orf-L-abor_.C.Mrd r..§....37OE7....I...-mttst;- immediately comply with those provisions or the agreement will automatically become void, Signature of applicant Date 5/10/18 65 Agreement for. P6443� Dated: Reviewed by:<- 1