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PROOF OF INSURANCE (2018 - 2018) CLOSED ACC>R " CERTIFICATE OF LIABILITY INSURANCE D03/29/2018Y) " 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 poiloy(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 CONI AC r NAME: HCC Specialty tYHMA No.ONE Prdo27VICEd1)n � I.t Apt A/C No) „ 401 Edgewater Place, Suite 400 �ADDRE'ss: Wakefield, MA 01880 CUSTOMER IID 0: INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURERA: New Hampshire Insurance Company 23841 Bobby Barron INSURER B: United States Fire Insurance Company 21113 5301 Cartwright Ave.#1 INSURERC: - -- North Hollywood, CA 91601 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 POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSRR TYPE OF INSURANCE AINSR SODA' POLICY'EFF') MM/DD/YY LIMITS --- _ WVD POLICY NUMBER (MMIDD/XYYY, YYY) GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X LIABILITY OCCUR PREMISE TORI=ccy=rJ 30rJ 006 X SEL013691518 04/04/2018 07/11/2018 DAMAGIs(EREWPren�el $ X MED FXP(Any one person) „�$ -„ --- „ COMMERCIAL GENERAL X Host Liquor PERSONAL&ADV INJURY $ 1,000,000 - -- ---- B X Medical Expense US969348 04/04/2018 07/11/2018 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000 XIPOLICY I. P CO'1, ---'. LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY HIRED AUTOS (Per accident) NON-OWNED AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN TORY(.IMITS,) � -F' ANY PROPRIETOR/PARTNER/EXECUTIVE E.L..EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) '"" E DISEASE-EA EMPLOYEE';$ it yes,describe under --- - --- . DESCRIPTION OF OPERATIONS below E .DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) The Certificate Holder is added as Additional Insured with respects to our Insured's operations only This insurance is primary and non-contribulory as required by written contract his coverage is with respect to EI Segundo Summer Concerts event to be held 07/08/2018-07/08/2018 at City of EI Segundo El Segundo CA CERTIFICATE HOLDER CANCELLATION City of EI Segundo, its Officers, Officials, employees, agents, and SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED volunteers IN ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main St. EI Segundo, CA 90245 AUTHORIZED REPRESENTATIVE ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. POLICY NUMBER: 13691518 COMMERCIAL GENERAL LIABILITY CG 20 11 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - MANAGERS OR LESSORS OF PREMISES This endorsement modifies 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 II — 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 11 0413 0 Insurance Services Office, Inc., 2012 Page 1 of 1 POLICY NUMBER: 13691518 COMMERCIAL GENERAL LIABILITY CG 20 26 0413 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): As submitted to company and required by written contract. 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 Section 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 injury" required 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; or 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 permitted by Declarations. 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 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1 I TM EIS Is 7 �MCATAs w. . . OFCERTIFICATE OF ONLY .UABUTY `CVRYNqCATR DOBE NOT AFFWMATWELY OR NEGATWELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THEE POLXXS BELOW TM TE. of RAVJRANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE IISIBL04 ff* ), AUTHORMED RIEPRISSIENTATIVII OR PRODUCER,AND THE CER 1 CATE HOLDER .. .Akii an AL MURED, mxh )• L OF ll . If SUBROGA11014 15 WNVIW�W*d to go tills I Ssld d des m) �" a111� E. A QEI *ft""Iflowla does In d ALii0FH .. u onsi roto epoprt 345 rA r is SUrfE 13M, 'a A N0, P S t SAN RIANC1800,CA 94104 httpJ/l&to/submit-request ............. 44191URSAM APPONDING OOVSRA= NAAR:rk 2017 'NKWMA-:WA WA Lm ft V e: Cwmw 2W las W"SL. CA 5000 ft"" :WA WA Sm Fwftm, 94107 jtgumt o:WA WA CO ... IOATE NOMI P 1 REVIS40N NUMBER: I" p „' THIS is To CERTIFY THATTHE.POLICIIES OF INSURANCE LI5TW BELOW HAVE BEEN ISSUED To THE INSURED NAMED ABOVE FOR'rHE POLICY PERIO INDICATED, NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RSSPSCT To WMKcI THIS CEJ~MFICATIE MAY 99 ISSUED OR MAY PERTAIN,,THE (INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUS39CT To ALL.THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH FOLIC(&LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. X" INSUKANCN 4AM-11110 um" MuML SUNory: Y,h MAIMS4AAOE O=UR =mwa MED 9W Wy ret PWWsq _l$ PERSONAL A ADY W-WY It A Te LIMIT APPLIES PER: l TE a POLICY PRO- F7 LOC Loc •OOAeAP1oP A , A a LLWLI Y 9AP42M4n1•02 10MWT 1wr"SLeap" a 1,000,000 ANY AUTO BODILY INJURY ) a OWNED� ONLY Nam(Pr pp a AUTOS ONLYAUTOS ONLY N a xSww 10 x InlAN a 1,000,000 UMBRIMLALIM dJ1SAa.MADE A a OCCUR EACH OCCURRONCS TE s � aa rUr ANYVRCVMNIA(.. PSC AVID l 1UL A i ! p 10NNS, E L DL9SIS8•EA a q1 rte' E.L DISEASE•POLICY LIMIT a ....... .,. .,,.., „..q... ..,. .,.,. OF TMRNILI LOGTIONE M (AGOIID 7D3, m�A bs M mon tr n 'Idmaa d 1 toa 5>. of GA C " IIINMI ' A E Lyh kr- SHOULD ANY OF THE AWMM DESCRISISID POLICHIS 99 CANCRILILSID BEFORE 155 9"8L,& t 5000 THE EXPIRATION DATE THERROF, NOT= MILL BE DELIVERED IN Sm Fnrdm CA 94107 ACCORDANCE WITH THE POLICY PROVOKM& TrwM 'd Mmsh Mak AWWrOM SWAM � Janna Boyce 10 ACORD"CORPORATKK . Ali. . ACORD 25 mo11Q1a) The ACORD nam a W lopo we registered marks of ACORD 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: L 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 EI Segundo is executed. My workers'compensation insurance carrier and policy number are: Carrier Policy Number Expiration Date Name of Agent Phone# 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 became act to the workers' compensation laws of California, and agree that, If I should become subje immediately cam with those to thew compensatlon provisions of Labor Code § 3700 1 must Signature of Applicant pra ' ant will auto�ioaily become void. 4/4/1 8 Print Name APP .... � .�"� Date Hobart brrrron Agreement for. Dated: ®q Reviewed b