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PROOF OF INSURANCE (2019) CLOSED ZEBRA-1 OP ID: JW CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)p 11/26/2018 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(ies) 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 805-553-0505 CO TACTMatt Wardlow Dick Wardlow Insurance Brokers PHONEFAX Lic.#OB99800 IA/'c No,EXI),805-553-0505 (AiC.No).805-653-0606 233 High Street ElheAl'L mat er@w rdiowinsurance.com Moorpark,CA 93021 A��IREs: Dick Wardlow Insurance Brokers MSURER,($')AFFORDINGCOVERAGE NA(CN INSURER A:Evanston Insurance Company INSURED Zebra Entertainment and Events INSURER B Shelly Mazer 11024 Balboa Blvd#118 INSURER C: Granada Hills,CA 91344 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, INSR ADDL'SUBR POLICY EFF POLICY EXP ITR TYPE OF INSURANCE INSP- /VD POLICY NUMBER fMM/DD/YYYY1 tM.M/DDJYYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR Y 3DS5466-M1225476 02/06/2018 02/06/2019 DAMA SEE TO R�E�NcT'ED nca} � 100,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GE,N'L AGGREGAI E LIMIT APPLIES PER: GFNFRAI AGGREGATE $ 2,000,000 X POLICY PRO- 1'000'000 JECT LOC PRODUCTS-COMP/C)P AGG $ AUTOMOBILE LIABILITY COMBINII°'0 Sft!Lf� II.IMI"T )'FaaGG„ardent/ ..$,,,,, ANY AUTO BODILY INJURY(Per person) `k AUTOSDONLY AUTOSULED BODILY INJURY(Per accident)„ $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident]) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ ER WORKERS COMPENSATION STATUTE „,ERH „.. AND EMPLOYERS'LIABILITY Y/N ANY OFFICER/MEMBER/EXCLU ED?ECUTIVE N/A E L EACH ACCIDENT $, (Mandatory in NH) E L DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) The City of El Segundo.,its officers, officials,employees, agents and volunteers are named'as Add"I Insureds,, but only�y insofar as the operations under this Written Contract are concerned. This (Policy is Primary & Non- Contributory. All Event Dates. CERTIFICATE HOLDER CANCELLATION CO-ES00 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of EI Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN y 9 ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street EI Segundo, CA 90245 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Policy Number: 3DS5466-M1225476 COMMERCIAL GENERAL LIABILITY CG 20 26 07 04 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) The City of EI Segundo, its officers, officials, employees, agents and volunteers 350 Main Street EI Segundo, CA 90245 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section II — Who Is An Insured is amended to in- clude as an additional insured the person(s) or organi- zation(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omis- sions 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 © ISO Properties, Inc., 2004 Page 1 of 1 ❑ COMMERCIAL GENERAL LIABILITY 111 POLICY NUMBER:3DS5466-M1225476 MARKEE' EVANSTON INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM SCHEDULE Name Of Person Or Organization: The City of EI Segundo, its officers, officials, employees, agents and volunteers 350 Main Street EI Segundo, CA 90245 Additional Premium: $ see Cert The following is added to Condition 8. Transfer Of Rights Of Recovery Against Others To Us under Section IV — Commercial General Liability Conditions: We waive any right of recovery we may have against any person or organization shown in the Schedule of this endorsement. This waiver applies only to the person or organization shown in the Schedule of this endorsement. All other terms and conditions remain unchanged. MEGL 0241-01 05 16 Includes copyrighted material of Insurance Services Office, Inc., Page 1 of 1 with its permission. POLICY NUMBER: 3DS5466-M1225476 COMMERCIAL GENERAL LIABILITY CG 20 01 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCECONDITION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance (2) You have agreed in writing in a contract or Condition and supersedes any provision to the agreement that this insurance would be contrary: primary and would not seek contribution Primary And Noncontributory Insurance from any other insurance available to the additional insured. This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: (1) The additional insured is a Named Insured under such other insurance; and CG 20 01 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1 " "A11611hh, ihinulih �AV ®' 0 MU'tk- En , and Events November 30, 2018 City of El Segundo 300 East Pine Avenue El Segundo, CA 90245 Regarding: 2018 Services Agreement To Whom It May Concern, This confirms that Zebra Entertainment and Events does not own or rent any vehicles, and therefore does not carry any Automobile Liability Insurance. We cannot cover vehicles privately owned by Independent Contractors. Our insurance carrier does not offer coverage for hired and non owned vehicles for our class of business. All the entertainers and operators that Zebra Entertainment and Events contracts with are Independent Contractors, not employees, so therefore we are not required to carry any Worker's Compensation policy for them, according to the California Labor Code. Thank You, I 6C 6e Shelly Mazer, owner Zebra Entertainment and Events 11024 Balboa Blvd, Suite 118 Granada Kills, California 91344 818-368-2818 www.ZebraEntertainmentAndEvents.com 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§37GO 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 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 immeditely Signatuae of Applily cant with those previsions or tyagr me�Vnt will automatically become void°Date •�/f'�� �� Print Name Agreement for: Dated: Reviewed by: ,