PROOF OF INSURANCE (2018 - 2018) CLOSED A431LU-1 OP ID:KH
CERTIFICATE OF LIABILITY INSURANCEFOSIM130120Z
M1uD
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 be endorsed.If SUBROGATION IS WAIVED,subject 1:6 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;leu of
such endorsoment(s),
PRODUCER CONTACT NAME Dale Wittick,Jr.,CPCU
PEEP Insurance,Inc. PHONE Fax
122 N.York Road,Suite 5 (Aa'C,No,Ext!: 15-733-7467INC,No,Ext):215-682-9948
Hatboro,PA 19040 ! ........................................................... t
Dale Wfttick,Jr.,CPCU E-MAIL ADDRESS:
INSURER(S)
AFFORDING CO
VERAGE .. BIC
INSURER A;Philadelphia Insurance Company 18
INSURED
INSURER B; I'
The International Jugglers'Association(IJA) INSURER C:
f EEP-C-20183472 INSURER D: -
David Cousin-Juggler
310 Larcom Street INSURER E:
A 91360 INSURER F:
Thousand Oaks,C � ..'
COVERAGES CERTIFICATE NUMBER:PEEP-C-2018-3472 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.
LTR TYPE OF INSURANCE............................i....L . ,...
ANS . SURR POLICY NUMBER._.,.,. ...........�
..............................................
POLICY EXP LIMITS
;NSR ..... .. ................. IYY. (MMIDD(YYYY)
A COMMERCIAL GENERAL LIABILITY X PHPK1665275 11101/2017 11/0112018 EACH OCCURRENCE $1,000,000
(Ea occurrence)T6ENTES
e) D PREMISE ...
........................... -
CLAIMS-MADEQOCCUR $100,000
❑ MED EXP(Any Dne person). ... _. s0
PERSONAL 6 ADV
❑ I INJURY 62,000,000
GEN'_AGGREGATE LIMIT APPLIES PER: GENE RAL AGGREGATE $2,000000
❑POLICY PROJECT LOC ...................
❑ ❑ � PRODUCTS-COM COMPIOP AG $2,000,000
OTHER-PER INSURED _.
AAUTOMOBILE LIABILITY CCOMBI QED SINGLE LIMIT(Ea
accide❑ANY AUTO BODILY INJURY(Per person
E]ALLOWNED ❑SCHEDULED
AUTOS AUTOS BODILY INJURY tParacdtlenq
❑HIRED AUTOS ❑NON-OWNED PROPERTY DAMAGE(Per
AUTOS accident)
lb EXCESS LA LIAB ❑ OCCUR EACH OCCURRENCE
"UMBRELLA LU1B ❑CLAfMSMADE AGGRECIAxB
W.
DED RET.....................,. .,„. --�
❑ ❑ ENTION S
WORKERS COMPENSATION AND PER STATUTE OTHER
EMPLOYERS'LIABIL[TY �❑ ❑
ANY YIN
PROPRIETORCPARTNERIEXECUTIVE® NIA E.4.EACH ACCIDENT
OFFICERJMEMBE,R EXCLUDED?
(MandatoryIn NH) E L DISEASE-EA EMP LIMI7 ..........
EMPLOYEE
It yes,describe under DESCRIPTION OF
OPERATIONS below
I
DESCRIPTION OF OPERATIONS 1'LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attachad if more space Is required)
Additional insured statue Is Included for all venues when it Is required and the insured is on premise.The Automatic Additional Insured endorsement is PI-MANU-1(01100)and was issued
with this certificate.The venue named in the Certificate Holder box is now added to the Wicy as an additional insured.
CERTIFICA H0LDER
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
The City.of EI Segundo,it's officers,officials,employees,agents and Certified EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE MTN
volunteer's THE POLICY PROVISIONS-
111 W.Marlposs Avenue AUTHORIZED REPRESENTATIVE
EI Segundo,CA 90245
C PGu
01988.2014 ACORD CORPORATION.All rights reserved.
ACORD 25(2014;01) The ACORD name and logo are registered marks of ACORD
POLICY NUMBER: PHPK1665275 COMMERCIAL GENERAL LIABILITY
CG 20 26 07 04
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - DESIGNATED
ARSON OR ORGANIZATION
This endorsement modifies Insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of AddMonal Insured Persona Or Or anlzatlon(s)
THE CITY OF EL SEGUNDO, ITS OFFICERS, OFFICIALS, EMPLOYEES AGENTS
AND CERTIFIED VOLUNTEERS
111 W. MARIPOSA AVENUE
EL SEGUNDO, CA 90245
Information required to complete this Schedule, if not shown above,will be shown in the Declarations.
Section 11 — Who Is An Insured Is amended to in-
clude as an additional Insured the person(s) or or-
ganization(s) shown in the Schedule, but only with
respect to liability for "bodily injury", "property dam-
age" or "personal and advertising injury" caused, in
whole or in part, by your acts or omissions or the acts
or omissions 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 0 ISO Properties, Inc.,2004 Page 1 of 1 0
PI-MANU-1 (01100)
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY
ADDITIONAL INSURED-PI EK 010
AUTOMATIC STATUS WHEN REQUIRED IN A CONTRACT OR AGREEMENT WITH YOU
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SECTION II-WHO IS AN INSURED is amended to include as an additional
insured:
1. Any person or organization for whom you are performing operations when
you and such person or organization have agreed in writing in a contract or
agreement that such person or organization be added as an additional insured
on your policy; or
2. Any person or organization for whom you are required to add as an
additional insured who is the owner or lessor of a premise/venue where
you are performing your operations on behalf of a third party who has a
written contract or agreement with such owner or lessor.
Such person or organization is an additional insured only with respect to
liability for"bodily injury,""property damage"or"personal and
advertising injury" caused, in whole or in part, by:
a. Your acts or omissions; or
b. The acts or omissions of those acting on your behalf;
In the performance of your ongoing operations for the additional
insured.
No coverage applies to liability resulting from the sole negligence of the
additional insured.
A person's or organization's status as an additional Insured under this
endorsement ends when your operations for that additional insured are
completed.
All other terms and conditions of this Policy remain unchanged.
Page 1 of 1
Evidence of Insurance FARMERS
State of California INSURANCIS
Named Divid W'.:olusliil.v Policy Num :194 1
imsuredo�.Hleiihor Cowln Ell 6/5/2018
Expiration:12/s/2010
VIIN:
cm.lsin JIr Tma Agent:Maim C Wlllim,s
1110 RAA IN
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AgentPliame(86)!ymovI
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Evidence of Insurance FARMERS
State of California INSURANCE
Named David W Cousin JF Poky Numbilul:194364081
lmiuradw:Heather Cousin Effective S/S/2018
Vehicle: 2013 Lexus Rx 350 4D 2Wd Exparilhom 12/5/2018
VIN:)7}ZKI6A91)2007243
RIII96-tered David W Cousinjr NAIL Number:21652
civisrsil Your Agent Mark C Williams
PO Box 79r9
Nen"Park,CA 99119
Agent Phone:(l 176 2818
F ii inuup,uu,iwriiii a:,Cly:mll',N 1111� :11llq III, Iwo I H
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II ,i :,I I, Ohl
il I I d I,I 0T',I I',I Ji I 1, 0
',Jl i bI 111111 I'l 11111: k IIL 1 1v 110V l:11 11111 A NA 1,1 11 1111,11111 IlhV 01 1 1 14'4414 PS k IVI z 111 R111;11 11 1;r"1
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.
PolicyNo. ..........................................
(_) 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 IFlotlicy Nur ber Expiration Date
Name of Agent I:11,ione# ... ......
(zV 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 those provnsuon5 the Agreement will automatically become void.
Signature of Applicant . -..... ..:.. .,.. .. d Date
+ a Y s u
Agreement for: .
Dated:
Reviewed by
1