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PROOF OF INSURANCE (2020) CLOSEDZEBRA -1 OP IM. J CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 11111 -^"" I 04/08/2019 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(les) 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 c' CT Matt Wardlow Dick 00 1. Wardl Insurance Brokers .„.E,�s'...805-653.0'505.....`�'FAX 05'-553-0606.............. 233 High Street Ab,,._mattw@v;ardFowInsurance.com wunsurance.com Moor�arark, CA 93021' Dick Crdlo'w Insurance Brokers er ainm'ent and Events as a. BClvd ti18 rens a ils, A 91 44 INSURERIS) AFFORDING COVERAGE, INSURER A: Evanston Insurance Company INSURER B: INSURER C: INSURER D: INSURER E: INSURER F; NAIC # 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 SUER POLICY EFF POLICY EXP R TYPE OF INSURANCE INSD WV POLICY NUMBER �Yyl LIMITS 00,000 DAMAGE TO RENTOD CLAIMS -MADE X LIABILITY EACH DOC URREN E $,,,,,,,,,,,,, A X COMMERCIALMGENERA�•l OCCUR X 3DS5468-M1115371 02/06/2019 02/06/2020 RR I SFSIEeocrunenrxL $ 1.'�o0,0oi� GEN'L AGGREGATE LIMIT APPLIES PER: XG I�PRp ....... POLICY q........M JECT LOC OTHER AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS AUTOS ONLY ............ AUTNOO�N4 UMBRELLA LIAB _ OCCUR EXCESS LIAB CLAIMS -MADE DED � I RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY 'Y / N A�YryN��Y PROPRIETOR/PARTNER/EXECUTIVE �LL--`, yNlnR4ry in NH)CLUDED? N / A Ifs, describe under DESCRIPTION OF OPERATIONS below MED EXP (Anv one person) s5,000„ PERSONAL&ADVINJURY S 1,000,000 GENERAL AGGREGATE s 2,000,000° PRODUCTS - COMP/OP AGG.....$..................................7..'....'0.O.a COMBINED SINGLE LIMIT' BODILY INJURY (Per„o„ersQn)........$............................................................... U.O. D,ILx_IN/.uR,Y.LP�r„accidlgpt).....5................ er aeciJe 1PAMAGE $ AGGRQGA FR.R,FNGE ....L.s $ .PER 10TH- ._-....... aSTATn�E.,._._.._ER _-E-LEACH EACH ACCIDENT $ E L. DISEASE- EA EMPLOYEE,$, EL DISEASE -POLICY LIMIT S 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 Ad'O Insureds, but onl Insofar as the operations Lander this Written Contract are concerned. This Policy Is P'r'imary & Non - Contributory. All Event Dates. C 11r;1W iii '.ir79i0 City of EI Segundo 350 Main Street EI Segundo, CA 90245 ACORD 25 (2016/03) CO-ES00 CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 3DS5468-Ml 115371 COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 WAIVER OF TRANSFER OF RIGHTS OF'RECOVERY ECOVERY AGAINST OTHERS TO SIS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART 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 Information required to complete this Schedule, if not shown above„ will be shown in the Declarations. The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV — Conditions: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products - completed operations hazard". This waiver applies only to the person or organization shown in the Schedule above. CG 24 04 05 09 © Insurance Services Office, Inc., 2008 Page 1 of 1 COMMERCIAL GENERAL LIABILITY 111 POLICY NUMBER: 3DS5468-Ml 115371 �WNW EVANSTON INSURANCE COMPANY 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 FORM 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 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 of this endorsement, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by the acts or omissions of any insured listed under Paragraph 1. or 2. of Section II — Who Is An Insured: 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 contractor 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. All other terms and conditions remain unchanged. MEGL 2217 01 19 Includes copyrighted material of Insurance Services Office, Inc., Page 1 of 1 with its permission. POLICY NUMBER: 3DS5468-M1115371 COMMERCIAL GENERAL LIABILITY CG 20 01 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. W.*."gn '" • • 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 Condition and supersedes any provision to the contrary: Primary And Noncontributory Insurance 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 (2) You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured. CG 20 01 0413 © Insurance Services Office, Inc., 2012 Page 1 of 1 i 1 �,....r •'•'• ill • 'ill 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, Shelly Mazer, owner Zebra Entertainment and Events 11024 Balboa Blvd Suite 118 Granada Hills, California 91344 818-368-2818 www.ZebraEnterlainmentAndEvents.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 § 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 # P I certify that, in the performance of the work set forth in the agreement with the City of EI Segundo, I will not mploy any person in any manner so as to become subject to the workers' compensation laws of Caiifomia, and agree that, if I should become subject to the workers' compensation provisions of Labor Code § 3700 1 must immediately comply with those provisions or t agrment will automatically become void. Signature of Applicant �—P. Date Print Name Agreement for: Dated: J40 E Reviewed by: