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PROOF OF INSURANCE (2019 - 2019) CLOSED DATE CERTIFICATE OF LIABILITY INSURANCE 9/21/2018 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 certificate holder is an ADDITIONAL INSURED,the policy(ios)must have ADDITIONAL INSURED provisions or 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 -. Contact Name: Larry Cossio Cossio Insurance Agency Phone (864)688-0121 Fax PO Box 5987 (A/C,No.Ext): (AIC,No): Greenville,SC 29606 E-Mail: shay@cossiainsurance.com (864)688-0121 INSURER(S)AFFORDING COVERAGE NAIC It INSURER A: NATIONWIDE MUTUAL INS CO 23787 INSURED Jump For Joy INSURER B: Berkley Life&Health Insurance Company 64890 530 South Francisca Avenue Redondo Beach,CA 90277 INSURER C: INSURER D: INSURER E: 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. INSR TYPE OF POLICY ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR X COMMERCIAL GENERAL LIABILITY INSR 4WD (MMIDDfYY) (MMIDDINY) General Agg(Other than Products-C $5,000,066' Each Occurrence $1,000,000 CLAIMS MADE Xl OCCUR Products and Completed Operations $1,000,000 Personal and Advertising Injury $1,000,000 A X FWC0002rJ3C23430D 9120/2018 912012019 Legal Liability to Participants $1.000,000 Professional Liability(for Event Plan $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER Damages to Premises Rented to You $300,000 X POLICY PROJECT LOC Participant Accident-Excess Modica $10,000 !OTHER: Deductible None COMBINED SINGLE LIMIT $ AUTOMOBILE LIABILITY (Ea accident) ANY AUTO BODILY INJURY(Per Person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED AUTOS PROPERTY DAMAGE $ (Peraccident) UMBRELLA LIAR OCCUR EXCESS UAB CLAIMS-MADE DED ! RETENTION$ WORKERS COMPENSATION PER OTH-� AND EMPLOYERS'LIABILITY STATUTE ER ANY PROPRICTORIPARTNER/EXECUTIVE YIN OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) If yes.d Dscnbe under DESCRIPTION OF OPERATIONS below Accident Medical Deductible $too Benefit Period 52 weeks B Accident Medical PAI L012010630901 9/20/2018 9120/2019 Benefit Maximum $500.000 Applies During per Covered Accident Applies To Death&Dismemberment Benefits only DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Party Equipment Rentals Operations located at 530 South Francisca Avenue Redondo Beach,CA 90277 Certificate Holder is listed as additional insured perform CG2026.The certificate holder is added as an additional insured,but only for liability caused,in whole or in part,by the acts or omissions of the named insured Amusement devices on file for special event(s)dated 09/21/2018-09119/2019 r / - CERTIFICATE HOLDER: CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of El Segundo THE EXPIRATION DATE THEREOF,NOTICE WILL BE DFLIVFRED IN 350 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. El Segundo,CA 90245 ;AUTHORIZED REPRESENTATIVE iD 1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: FWC0000030234300 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 Organ City of EI Segundo 350 Main Street EI Segundo, CA 90245 Re: Special event(s) dated 09/21/2018—09/19/2019 located at various locations throughout the The city, state or governmental agency or subdivision shown in the Schedule is subject to the following provision: 1.This insurance applies only with respect to operations performed by you or on your behalf for which the city,state or governmental agency or subdivision has issued a permit or authorization. Coverage does not extend to the negligence or errors&omissions of the additional insured. 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 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 Declarations. insured only applies to the extent permitted by 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 ©Insurance Services Office, Inc., 2012 Page 1 of 1 TRAVELERSJ Automobile Policy continuation Declarations 1. Named Insured Your Service Center Address RON &VALERIE IACOPUCCI KNOXVILLE BUSINESS CENTER 530 S FRANCISCA AVE APT#B P 0 BOX 59059 REDONDO BEACH, CA 90277-4241 KNOXVILLE, TN 37950-9059 Your Insurer TRAVELERS COMMERCIAL INSURANCE COMPANY ONE TOWER SQUARE, HARTFORD, CT 06183 Your Auto Policy Number 996024601 203 1 For Policy Service 1-800-842-5075 Your Account Number 941113867 For Claim Service 1-800-252-4633 1-1. --" - .---............ .......... ................. 2. Premium Your Total Premium for the Policy Period is $1,577. The policy period is from August 1, 2018 to February 1, 2019 12:01 A.M. STANDARD TIME at your address shown in Item 1. ........... 3. Your Vehicles Identification Numbers 1. 2006 TOYOT TUNDRA LIM 5TBDT48126S519837 2. 1990 FORD F350 2FDKF37M1LCA88678 3. 2001 TOYOT AVALON XU 4T113F2813111-1131498 4. 2010 TOYOT PRIUS JTDKN3DUXA0148831 4. Coverages, Limits of Liability and Premiums Insurance is provided only where a premium entry is shown for the coverage. The premium entry"Ind"or"Pkg" N means the premium charge is included in the premium for another coverage or a package. VEHICLE 1 VEHICLE 2 VEHICLE 3 VEHICLE 4 06 TOYOT 90 FORD 01 TOYOT 10 TOYOT TUNDRA LIM F350 AVALON XU PRIUS A. Bodily Injury $100,000 each person $300,000 each accident $221 $250 $161 $180 B. Property Damage $50,000 each accident $105 $88 $61 $70 D1. Uninsured Motorists Bodily Injury $100,000 each person $300,000 each accident $49 $65 $49 $49 E. Collision Actual Cash Value less $2,500 deductible $72 $34 $74 T. Waiver of Collision Deductible $2 $2 PL-50014(03-12) Page 1 of 4 670/OM1605 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. affirm under penalty of perjury under the laws of California one of the following declarations: L) 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. L)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# CN 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 Signature Applicant mpllwith those ro "' � greemeril will automatically become void. Y comply P ,sons or the ag 9 _. Date Print Name "NJ ...........................................................w Agreement for:��l � UTA Dated: Reviewed by: � '