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PROOF OF INSURANCE (2019 - 2020) CLOSEDA� " CERTIFICATE OF LIABILITY INSURANCE DATE A 03/05/2o YYY) ��9 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(les) must have ADDITIONAL INSUREDrovisions 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: mass merCnanaism PHOE FAX K&K Insurance Group, Inc. BArCd'Nr Ext ; 1-800-328-2317 AJC 1-260-459-5502 1712 Magnavox Way E-MAIL Fort Wayne IN 46804ADDRESS, info@eventinsurance-kk.com Pi1ODUCER CUSTOMER lD: INSURER(AF , S FORDINGCOVERAGE NAIC# INSURED 2001092247 CP# 1226 INSURER A: Nationwide Mutual Insurance Com an 23787 Flogging Seagulls/Celter Skelter INSURER B: P.O. Box 140 INSURER C: South Pasadena, CA 91031 INSURER D: A Member of the Sports, Leisure & Entertainment RPG INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 2000408066 REVISION NUMBER: TH11 I 11 S 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 INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR WSD wVD ....... MM/DD/YYY MM/DD/YYY A X COMMERCIAL GENERAL LIABILITY X 6BRPG0000006426100 03/15/19 03/15/20 EACH OCCURRENCE $1,000,000 12:01 AM 12:01 AM DAMAGE TO RENTED $1,000,000 (CLAIMS -MADE OCCUR PREMISES (Ea OccurrenceL_ MED EXP (Any one person), Excluded PERSONAL & ADV INJURY Excluded GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $5,000,000 POLICY ❑ PROJECT ❑ LOC PRODUCTS - COMP/OP AGG $1,000,000 OTHER: PROFESSIONAL LIABILITY LEGAL LIAB TO PARTICIPANTS $1,000,000 COMBINED SINGLE LIMI I AUTOMOBILE LIABILITY accident ( a ANY AUTO BODILY INJURY (Per person) OWNED SCHEDULED - WW4YW -- AUTOS ONLY AUTOS BODILY INJURY (Per accident) HIRED NON -OWNED PRC7PERTY OAMAGE. AUTOS ONLY AUTOS ONLY Per accident X Not provided while in Hawaii U OCCUR EACH OCCURRENCE LIAB EXCESS LIABCLAIMS-MADE AGGREGATE DED RETENTION WORKERS COMPENSATION N/A PER STATUTE OTHER AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/ Y / N E . EACH ACCIDENT EXECUTIVE OFFICER/MEMBER- ....... EXCLUDED? (Mandatory in NH) El E L, DISEASE- EA EMPLOYEE If yes, desedbe under DESCRIP`r ON OF OPERATIONS below EL, DISEASE -POLICY LIMIT A MEDICAL PAYMENTS FOR PARTICIPANTS 03/15/19 03/15/20 1 PRIMARY MEDICAL $5,000 6BRPG0000006426100 12:01 AM 12:01 AM EXCESS MEDICAL DESCRIPTION OF OPERATIONS P LOCATIONS dVEHICLES (ACORD 161„ Addif lunal Remarks Schedule, may be attached if more space is required) Type of Group: Musicians, singers or vocalists, Non -touring bands (tribute, wedding, garage); Music Genre: Pop/soft rock; Type of Venue: Bars, Nightclubs, Outdoor venues, Reception halls Event Date: 06/16/2019 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 nam insured. CERTIFICATE HOLDER CANCELLATION City of EI Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE 150 Illinois Street EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH EI Segundo, CA 90245 THE POLICY PROVISIONS. Owner/Manager/Lessor of Premises AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION, All rights reservet! Coverage is only extended to U.S. events and activities. ** NOTICE TO TEXAS INSUREDS: The Insurer for the purchasing group may not be subject to all the insurance laws and regulations of the State of Texas. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 6BRPG0000006426100 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 Organization(s) City of EI Segundo 150 Illinois Street EI Segundo, CA 90245 Named Insured: Flogging Seagulls/Celter Skelter CP# 1226 I Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(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 omissions of those acting on your behalf: 1. In the performance of your ongoing operations; or 2. In connection with your premises owned by or rented to you. However: 1. The insurance afforded to such additional 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. B. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. CG 20 26 04 13 0 Insurance Services Office, Inc., 2012 Page 1 of 1 Evidence of Insurance Here are your Evidence of Liability Insurance Cards Two cards have been provided for each vehicle insured. One card must be carried in the proper insured vehicle. Proof of insurance is required to register or renew the registration of your vehicle. A law enforcement officer can ask you to prove that you have liability insurance meeting the basic requirements of California law. A violation of these requirements can result in a fine of up to: $1,000 for the first time $2,000 for additional times Also, a judge can have your vehicle impounded. False proof of insurance may result in a fine up to $750 and 30 days in prison. Due to space limitations on the ID card, only the Named Insured and the Co-insured are listed. For a full list of drivers covered under this policy, please reference the Drivers section of your Declarations Page, which is included with your insurance packet. If you would like additional ID cards you can go online to geico.com or call us at 1-800-841-3000. California Evidence of Liability Insurance GEICM 901,0a cam 1-800-841-3000 GEICO INDEMNITY COMPANY P.O. Box 509090 • San Diego, CA'92150-9090 NAIC Code: 22055 Policy Number Effective Date Expiration Date 1677-96-74-06 02-12-19 08-12-19 Year Make 2016 JEEP Insured: Zadra Ibanez Damon Pipitone Po Box 140 South Pasadena CA 91031 Model Vehicle ID No. PATRIOT 1C4NJPBAXGD698248 The coverage provided by this policy meets the minimum requirements of sections 16056 & 16500.5 of the California Vehicle Code, minimum liability limits prescribed by the law. ZADRAIBANEZ PO BOX 140 SOUTH PASADENA CA 91031 CJEICC)Californian��fornia�Evidence of Liability 98110 ►.Com 1-800.841-3000 GEICO INDEMNITY COMPANY P.O. Box 509090 • San Diego, CA 92150'=9090 NAIC Code: 22055 Policy Number Effective Date Expiration Date 1677-96-74-06 02-12-19 08-12-19 Year Make Model Vehicle ID No. 2016 JEEP PATRIOT 1C4NJPBAXGD698248 1 Insured: Zadra Ibanez Damon Pipitone Po Box 140 South Pasadena CA 91031 The coverage provided by this policy meets the minimum requirements of sections 16056 & 16500.5 of the California Vehicle Code, minimum liability limits prescribed by the law. What to do at the time of an accident. • Do not admit fault. • Do not reveal the limits of your liability coverage to anyone. • Exchange contact information; get year, make, model, plate number, insurance carrier and policy number of all involved. Also, identify witnesses and collect contact information. • Contact the police or 911 if applicable. • Contact GEICO by calling 1-800-841-3000 or visit geico.com to report the accident. U -4 -CA (11-09) What to do at the time of an accident. • Do not admit fault. • Do not reveal the limits of your liability coverage to anyone. • Exchange contact information; get year, make, model, plate number, insurance carrier and policy number of all involved. Also, identify witnesses and collect contact information. • Contact the police or 911 if applicable. • Contact GEICO by calling 1-800-841-3000 or visit geico.com to report the accident. U -4 -CA (11-09) 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. l afR rlIll ub11der penafty of perjury under tlhe Paws of C;,aNnfc rn� a one of the fo0low�ing decNaratbons: (_) 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.._................._........................_....._.................................._. _m ��_..................................................................._... (_) 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 # ('- C c',rtify that, in the performanp.a, of the work set forth in the agreement with the City of EI Segundo, I will not employ any person in any ¢ u,,wrurzrQr°wr so as to become sylOject to the workers' compensation laws of California, and agree that, if I should t)ecor6e to the wwhs'llrrey:m�,. provisions of Labor Code § 3700 1 must immediately comply with 4c��, automatically become void Signature of Applicant .. __ Date . Print Name Au.eettCrtt t' Dated: Reviewed