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PROOF OF INSURANCE (2019) CLOSED ATE AC CERTIFICATE OF LIABILITY INSURANCE D 10/25/20 8Y) 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 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 CONTACTTANIIIA RICHARDSON NAME cr Rx* 00 310-323-8171 TAN IA I FAX S a BFBr 17715 HAW RCREDNSBLVD EA OINSURANCE AGENCY, INC E-MAIL s:Tarlla.I 11 rdslalelarm,com DRE s ort tpw5�,,.., . TORRANCE, CA 90504 INSURERA: SURER(S)lrAAFFORDING COVERAGE NAIC# 04 State Farm pany 25151 INSURED VISION ADELANTE INSURER B: DBA PARTY POSIES INSURERC: 1267 SARTORI AVE INSURER D; TORRANCE, CA 90505 INSURERS 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. IryTR INSDI TYPE OF INSURANCE AobL_11SUBAi POLIO ....... POLICY 1(�[t[D NUMBER RMMdDDPYYYYd fMMdiC1Dd'Y"YYYh LIMITS COMMERCIAL CLAIMS-MADE LIABILITY r�kMAde RRENCE $ 1,000,000 A O ... OCCUR PREMISES JFa o lcune i ., X MERCIAL GENERAL EACH OCCU a cor:urrcencei S XBUSI NESS 92-B7-P154-9 G 07101/2018 07/01/2019 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ G EOAGGCYREGAT P", RMT APPLIES IPE PRODUCTS GCOMP OP AGGS, 2,000,000 JFcT OTHER', $ COMB ED SINGLE LINUT ANYAUTOED ' SCHEDULED 92-B7-P154-9G 07/01/20113 07/01/2019 °°BODILLYINJURY IPero $ 1,000,000 AUTOMOBILE LIABILITY ( accident) $ INJUR Per LL AUTOS _I AUTOS .. NON-OWNED 6 ., ...,, HIRED AUTOS X I AUTOS d,ROPER�Y APAA4"E II UMBRELLA LIAB I OCCUR EACH OCCURRENCE $ EXCESS LIAB AGGREGATE $ - , CLAIMS-MADE DED I RETENTION$ $ WORKERS COMPENSATION PER STATUTE ORH AND EMPLOYERS'LIABILITY YIN ANY PROPRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE„$ If yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) AUTOMATIC RENEWAL-If the Policy Period is shown as 12 months,this policy will be renewed automatically subject to the premiums,rules and forms in effect for each succeeding policy period.If this policy is terminated,we will give you the Mortgagee written notice in compliance with the policy provisions oras required by law: 10 days before the effective date of cancellation if we cancel for nonpayment of premium;30 days before the effective date of cancellation if we cancel for any other reason. 350 MAIN ST EL SEGUNDO CA 90245-3895 CER'TIF'ICATE HOLDER CANCELLATION THE CITY OF EL SEGUNDO ITS OFFICERS, OFFICIALS, SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE EMPLOYEES,AGENTS, $VOLUNTEERS THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ATTN CITY CLERK ACCORDANCE WITH THE POLICY PROVISIONS. 350 MAIN ST EL SEGUNDO CA 90245-3895 . E AUTHORIZED REPRESENTATIVE I ©1988-201 CORD CORPORATION.All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD 1001486 132849.9 02-04-2014 CH Policy No. 92 B72154 9 0919—FA75 N CMP-Page 1 06 9 2 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, CMP-4786.1 ADDITIONAL INSURED—OWNERS, LESSEES, OR CONTRACTORS (Scheduled) This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM SCHEDULE Policy Number: 92 B7P154 9 Named Insured: VISION ADELANTE DBA PARTY POSIES 1267 SARTORI AVE TORRANCE CA 90501-2720 Name And Address Of Additional Insured Person Or Organization: THE CITY OF EL SEGUNDO ITS OFFICERS, OFFICIALS, EMPLOYEES AGENTS & VOLUNTEERS ATTN CITY CLERK 350 MAIN ST EL SEGUNDO CA 90245 3895 1. SECTION II — WHO IS AN INSURED of b. If coverage provided to the additional in- SECTION II — LIABILITY is amended to in- sured is required by a contract or agree- clude, as an additional insured, any person or ment, the insurance provided to the organization shown in the Schedule, but only additional insured will not be broader than with respect to liability for "bodily injury", that which you are required by the contract '°property damage"", or""personal and advertis- or agreement to provide for such addition- ing injury'"caused, in whole or in part, by: al insured; and a. Ongoing Operations c. If the contract or agreement between you (1) Your acts or omissions; or and the additional insured is governed by (2) The acts or omissions of those acting California Civil Code Section 2782 or on your behalf; 2782.05, the insurance provided to the additional insured is the lesser of that in the performance of your ongoing opera- which: tions for that additional insured; or b. Products–Com Completed Operations (1) Is allowed for the satisfaction of a de- b. P fense or indemnity obligation by Cali- "Your work" performed for that additional fornia Civil Code Section 2782 or insured and included in the "products- 2782.05 for your sole liability; or completed operations hazard". (2) You are required by contract or However, Paragraph 1. above is subject to the agreement to provide for such addi- following: tional insured. a. The insurance afforded to the additional We have no duty to defend or indemnify the insured only applies to the extent permit- additional insured under this endorsement un- ted by law; til a claim or"suit" is tendered to us. ©,Copyright,State Farm Mutual Automobile Insurance Company,2013 Includes copyrighted material of Insurance Services Office,Inc.,with its permission. CONTINUED CMP-4786.1 Page 2 of 2 2. Any insurance provided to the additional in- (3) The nature and location of any injury sured shall only apply with respect to a claim or damage arising out of the "occur- made or a "suit" brought for damages for rence"or offense; which you are provided coverage. b. Tender the defense and indemnity of any 3. With respect to the insurance afforded to the claim or "suit" to us and to all other insur- additional insured, the following is added to ers who may have insurance potentially SECTION II—LIMITS OF INSURANCE: available to the additional insured; and If coverage provided to the additional insured c. Agree to make available any other insur- is required by contract or agreement, the most ance the additional insured has for de- we will pay on behalf of the additional insured fense or damages for which we would will be the lesser of the amount of insurance: provide coverage under SECTION II — a. Required by the contract or agreement; or LIABILITY. b. Available under the applicable Limits Of 5. With respect to the insurance afforded the ad- Insurance shown in the Declarations. ditional insured, the following replaces SEC- TION II —LIABILITY of Paragraph 7. Other This endorsement shall not increase the ap- Insurance of SECTION I AND SECTION II — plicable Limits Of Insurance shown in the COMMON POLICY CONDITIONS: Declarations. a. This insurance is primary to and will not 4. With respect to the insurance afforded to the seek contribution from any other insurance additional insured, the following is added to available to the additional insured, provided Paragraph 3. Duties In The Event Of Occur- that the additional insured is a named in- rence, Offense, Claim Or Suit of SECTION sured under such other insurance. II—GENERAL CONDITIONS: b. Regardless of any agreement between The additional insured must: you and the additional insured, this insur- ance is excess over any other insurance a. See to it that we are notified as soon as whether primary, excess, contingent or on practicable of an "occurrence" or an of- any other basis for which the additional in- fense which may result in a claim. To the sured has been added as an additional in- extent possible, notice should include: sured on other policies. (1) How, when and where the "occur- There will be no refund of premium in the event rence"or offense took place; this endorsement is cancelled. (2) The names and addresses of any in- jured persons and witnesses; and All other policy provisions apply. CMP-4786.1 1007033 148011 08-21-2014 O,Copyright,State Farm Mutual Automobile Insurance Company,2013 Includes copyrighted material of Insurance Services Office,Inc.,with its permission. 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: U 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# I certify that, in the performanc of the work set forth in the agreement with the City of EI Segundo, I will not e ploy any person in any manner. ' 'as to become subject to the workers' compensation laws of California, and agree that, if I should become s ct to the workers' compensation provisions of Labor Code § 3700 1 must immediately comply with those pr ns or the agreement will automatically become void. Signature of AP licant ,r `� `� Date r ,f" Print Name , " P�P ,c1u Agreement for: R � Dated: .._- Reviewed by: -1��