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PROOF OF INSURANCE (2019 - 2019) CLOSED CERTIFICATE OF LIABILITY INSURANCE DATE MM/DDIYYYY) �' I 021(73/2019 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 CONTACT NAME; Sam Muradyan Liberty United Insurance Services,Inc PHONE FAX 704 S Victory Blvd,Suite 204 -("—No Ell 8187618888 INC,No); 88812656889 Burbank,CA 91502 ADDRESS: Sam 'libertyunitedinsurance.com INSYRER S)AFFORDING COVERAGE NAIC .. . : ILicense#. OF89841 INSURERA: Admiral In surance Company . . INSURED INSURER B: Elite Special Events,Inc INSURER C: 11278 Los Alamitos Boulevard#101 INSURER D: Los Alamitos,CA 90720 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 00000000-279009 REVISION NUMBER: 214 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 CONTRACTOR 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 INSRTYPE OF INSURANCE IADDL t,UBR POLICY'EFF POLICY EXP I LTR INSD WVD POLICY NUMBER IMMIDD/YYYY)((MMIDD/YYYY)I LIMITS A X COMMERCIAL GENERAL LIABILITY Y Y CA000032316-01 10/28/2018 10/28/2019 1,000,1000 J CLAIMS-MADEAM-AG- o�a® $ 30000,0❑ qce) MED EXP{any one person) 5 52000 PERSONAL 8 ADV INJURY s, ,1„/0001000„ LOC PR G GREGATE $ 2,000,000 POLICR ❑ EC ❑ ODUACTSGCOMP®PAG $ 2,000,000 GEN,AGGREGATE LIMIT APPLIES PER: o,m LAUTOMOBILE LIABILITY COMBINED SINGLE L,IM@T ._....... .(EA accident) $ . ANY AUTO BODILY INJURY(Per person) $ 4 OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY ,,,, �„ AUTOS ' HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ j EXCESS LIABAGGREGATE $ PED ❑RETENTION$.CLAI,MS.-M,ADE......... $ .......,,,. WORKERS COMPENSATIONPER OrrI AND EMPLOYERS'LIABILITY YIN STATUTE,,, „I;CS ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ E L EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? NIA (Mandatory in NH) EL 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 he attached if more space is required) City of EI Segundo,its officers,officials,employees and volunteers are listed as additional insureds CERTIFICATE.HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN City of EI Segundo ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street EI Segundo, CA 90245 AUTHORIZED REPRESENTATIVE & � � (SMS) ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Printed by SMS on February 13,2019 at 12:09PM Policy Number: CA000032316-01 CG 20 26 04 13 Effective Date: 10/28/2018 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): City of El Segundo,its officers,officials,employees and volunteers 350 Main Street El Segundo,CA 90245 information required to complete this Schedule,if not shown above,will be shown in the Declarations. V A. Section ii—Who is An insured is amended to include B. With respect to the insurance afforded to these addi- as an additional insured the person(s)or organization(s) tional insureds,the following is added to Section iIi— shown in the Schedule,but only with respect to liability Limits Of insurance: for"bodily injury", "property damage" or"personal and if coverage provided to the additional insured is re- advertising injury"caused, in whole or in part,by your quired by a contract or agreement,the most we will pay acts or omissions or the acts or omissions of those act- on behalf of the additional insured is the amount of fin- ing on your behalf: surancc: 1. In the performance of your ongoing operations;or 1. Required by the contract or agreement;or 2. In connection with your premises owned by or 2. Available under the applicable Limits of insurance rented to you. shown in the Declarations; However: whichever-is less. 1. The insurance afforded to such additional insured This endorsement shall not increase the applicable Lim- only applies to the extent permitted by law;and its of Insurance shown in the Declarations. 2. If coverage provided to the additional insured is re- quired by a contract or agreement,the insurance af- forded 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 Oc Insurance Services Office,Inc.,2012 Page 1 of 1 13 DATE(MMIDDIYYYY) ACC?R" CERTIFICATE OF LIABILITY INSURANCE 02/13/2019 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 NA�M1EAC'1 Dave Warren Nielsen McAnany Insurance Services,Inc, PHONE (805)379-8801 1 PAX (805)204-4501 41 4165 E Thousand Oaks Blvd AVL ADDRESS: .Suite 325 INSURER(S)AFFORDING COVERAGE NAIC 0 ......... .._. ........... ...— ..............., Westlake Village CA 91362 INSURERA: Califomia Auto Insurance 38342 INSURED INSURERS: ELITE SPECIAL EVENTS,Inc. INSURER C: ........................................� 404 N Sparks St INSURER D _......................................__............................... INSURER E: ........................ Burbank CA 91506-1963 INSURER F: COVERAGES CERTIFICATE NUMBER: CL1881505297 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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. ...... _._.__-.... TNB ......._._...............................TYPE OF INSURANCE A SID WVi ft".,..,.,.,.,.,......,.,.,_ POLICY NUMBER 'MIDDI� IDDIY Y(Y) LIMITS LTR INSD WVD {MMIpDIVYVY) (MMIDDIYVYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ ......... DAMAGE RX. ...............� CLAIMS-MADE 1-OCCUR PREMIS r5 E'1 perSr"t^'c .l.............. $ MED EXP(Any one person) $ ........................ PERSONAL B ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ PRO. POLICY JECT. LOC PRODUCTS-COMP/OP AGG S OTHER: $ AUTOMOBILE LIABILITY �COMBINED SINGLE OWI $ 1,000,000 denq'q ....................,............ ANYAUTO BODILY INJURY(Per person) $ OWNED SCHEDULED A BA040000023533 08/31/2018 0813112019 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS I HIRED NON-OWNED —PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY R,P.er accidehil....,_„_„_„__„_„_„_ .._...., ......................... I .._.._.._.._.._.._.._.._-._....._............ $ ........... UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ ITDED L I RETENTION$ $ WORKERS COMPENSATION _. _ _. PEATUTE OR H_ AND EMPLOYERS'LIABILITY Y 1 N �� ANY PROPRIETOR/PARTNER/EXECUTIVE [-7 NIA E L EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) _LL DISEASE-EA EMPLOYEE $ DESCdescdbe under RIPTION OF OPERATIONS below E L._....w._ .................. - ,DISEASE-POLICY LIMIT $ DESCRIPTION .......... OF OPERATIONS 1 LOCATIONS 1 VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) The City of EI Segundo,its officers,officials,employees,agents,and volunteers are named as additinal insured per attached MCA85100817 10 days notice of cancellation for non payment of premium CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN City of EI Segundo ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street s AUTHORIZED REPRESENTATIVE EI Segundo CA 90245 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ,AAA MERCURY I NSURANCE Business Auto Broadening Endorsement Newly Acquired or Formed Entity (Broad Form Named Insured) —Adds, as an insured, any newly | acquired or formed entity provided the insured owns at least 50% of that entity and it is formed during the policy period. The maximum period io18Odays. Primary and Non-Contributory if Required by Contract—We will not seek contribution from any other insurance available under specific conditions. Employees as Insureds—An employee becomes an insured while using a covered auto that the insured does not own, hire or borrow. Automatic Additional Insured —Any person or organization that the insured is required to include mgonadditional insured based mnmcontract oragreement that imexecuted prior tothe injury or damage. Employee Hired Auto —An employee is an insured when operating an auto that is hired or rented inthe employee's name while oncompany business. Supplementary Paynnents— Bail bonds coverage is increased to $3.000. Reasonable expenses and loss of earnings, up to $500 per day, incurred by the insured are covered. Fellow Employee Coverage—The exclusion has been removed. Additional Transportation Expense —VVmwill pay upto $5Oper day, maximum i8 $1.O0O. for " temporary transportation expense resulting from the total theft of a covered auto. Hired Auto Physical Damage Coverage— If you have Hired Auto Liability cOxer8ge, and you carry physical damage coverage for any of your autos, we will extend coverage for Hired Auto Physical Damage toolimit mf$5O.00O. subject hoa $500 deductible. Accidental Airbag Deployment—VVmremoved the exclusion, providing coverage for airbag deployment that is accidental. Loan/Lease Gap—Coverage for the unpaid amount due on the lease or loan has been added if there is a total |ooe of an auto insured under this policy. Glass Repair— Deductible Waiver—VVewill waive the deductible ifglass iorepaired rather than replaced. Two or More Deductibles— If two or more policies or coverage forms from the company apply to ' the same accident, only one deductible will beapplied. Amended Duties in the Event of Accident, Claim, Suit or Loss —The insured must notify us of an accident aasoon aepossible. . Waiver of Subrogation —We waive our right of recovery against others if the insured has executed � awritten agreement prior tothe accident orloss. ' Unintentional Error, Omission, or Failure to Disclose Hazards —The policy will not be deemed invalid if the insured unintentionally omits, errs or fails to disclose a hazard. Employee Hired Auto - If the employee hires or rents a vehicle with permission of the insured, ' Hired Auto Physical Damage applies. HiredAuto —CoverageTerritory—Cmveroge applies anywhere inthe world ifanauto |e |eB8gd | ' | himad, rented or borrowed without o driver for o period of 30 days or|eoo, and the ineunad'o responsibility to pay for damages is determined in a suit brought in the US, its territories and possessions, Puerto Rico, Canada orinosettlement that vveagree to. Bodily Injury Redefined to Include Resultant Mental Anguish — Bodily Injury includes nlenta| anguish. CA.A2.TX.OK.8A1D'1G n | 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 forthe performance of the work set forth the agreement with the City of El Segundo. Policy No. I (_}I have and will maintain workers'compensation insurance as required by Labor Code§3700 forthe 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# (X 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 immediately comply with those proviss or the agreem utomatically become void. Signature of Applicant — Date Print Name Agreement for: Dted nc Reviewed by: