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PROOF OF INSURANCE (2019 - 2020) CLOSEDI � II DATE (MM/OD/YYYY) �'" CERTIFICATE OF LIABILITY INSURANCE V �-° MARKEL" 4/17/2019 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 CONTACT Stephanie Weiss NAME: P Per oBotx 24 Insurance Agency )apREss: 8 Ce FAX Specialty g y 15 246-4257 Performers of the U.S. tG 8� extl; _. � lac No) 715-246-890 7 E MAIL y° agenc'y.com Darla@speclalt Insuran„ New Richmond, WI 54017 INSURERS)„ AFFORDING COVERAGE NAIC# ....,....... INSURERA: Evanston Insurance Company 35378 INSURED Eric R. Greenberg INSURER B :, ...................... .........,,,,, .-- dba Liberty City 18560 Vanowen St, Unit 14 INSURER C a Reseda, CA 91335_LSt RER o..' ................................. _MED EXP (Any one person) ............INJURY .INSURER E 5,000�� INSURER F: COVERAGES CERT'IFICA'TE 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 TYPE OF INSURANCE AbbLtUaR POUC i PoLid"FEFF 06 ICY EXP I LIMITS LTR IIS YNUMBER !MM/DD/YYYYI (MMIDDNYYYI X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 �I CLAIMS -MADE TIOCCUR A X X 2CN0165-2490 GEN'L AGGREGATE LIMIT APPLIES PER: LL. POLICY...m,.. PRO ❑ LOC AUTOMOBILE�LIABILITY .... JANY AUTO OWNED SCHEDULED _ AUTOS ONLY _ AUTOS HIRED NON -OWNED AUTOS ONLY Iii AUTOS ONLY UMBRELLA LIAB OCCUR CESS LIAB N DED RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N AN'YPROPR'IETORMARTNER/EXECLIITWVE ❑ OFFICERIMEMSERFACLUC N / A (Mandatory In NH) 'll yew, describe vender DESCRIPTION OF OPERATIONS below A BUSINESS PERSONAL PROPERTY - INLAND MARINE C3APs 6t 110 i%t'i'VTFa 000 PREMI.,5 4 r:,. ce a tical— $00 -- ........... _MED EXP (Any one person) ............INJURY $ 5,000�� 04/25/2019 04/24/2020 PERSONAL aADV $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 TS - COMP/OP AGG PRODUCED $ 2,000 ,000 .... -- -_..,.. $ ... COMBINED SINGLE LIMIT $ . (EP,45.00m) __ . BODILY INJURY (Per person) $ Y BO(Per accident) $ PERTY DAMAAbE PROP $ .,Vf av a�rxwderl@1 .., EACH AGGREGATERENCE $, ................ SOTH- TATUTE. 1 ..15R, E.L. EACH ACCIDENT ................... $ E.L DISEASE - EA E MPLOYEE$ E,L. DISEASE - POLICY LIMIT $ AGGREGATE $ DESCRIPTION OF OPERATIONS/ LOCATIONS/ VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) PERFORMER IS A NAMED INSURED AS A MEMBER OF PERFORMERS OF THE U.S.: Eric R. Greenberg dba Liberty City Additional Insured: The City of EI Segundo, it's officers, officials, employees, agents and certified volunteers are named as additional insured, but only insofar as the operations under this contract are concerned Fax: 818-344-6108 Email: libertycityedc@aol.com Event Date: Ongoing for policy period CERTIFICATE FOLDER CANCELLATION City of EI Segundo 350 Main Street, Room 5 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE EI Segundo, CA 90245-3813 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE �.c'f•.' 'Avg`'` �/i�/�/ @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 2CN0165-2490 COMMERCIAL GENERAL LIABILITY CG 20 01 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. 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 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1 COMMERCIAL GENERAL LIABILITY POLICY NUMBER: III 2CN0165-2490 ANEr EVANSTON INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET WAIVER OF SUBROGATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM SCHEDULE Additional Premium: $ 0 Name of Person or Organization: Any person(s) or organization(s) to whom the Named Insured agrees to waive rights of recovery in a written contract. The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV — COMMERCIAL GENERAL LIABILITY CONDITIONS) is amended by the addition of the following: We waive any right of recovery we may have against the person or organization shown in the Schedule above as respects written contracts that exist between you and such person or entity, provided you have agreed in writing to furnish this waiver. This waiver applies only to the person or organization shown in the Schedule above. All other terms and conditions remain unchanged. MEGL 0241-01 04 11 Includes copyrighted material of Insurance Services Office, Inc. with its Page 1 of 1 permission. COMMERCIAL GENERAL LIABILITY POLICY NUMBER: III2CN0165-2490 I A► 1." EVANSTON INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED This endorsement modifies insurance provided under the following COMMERCIAL GENERAL LIABILITY COVERAGE FORM PRODUCTS/COMPLETED OPERATIONS COVERAGE FORM LIQUOR LIABILITY COVERAGE FORM PROFESSIONAL LIABILITY COVERAGE FORM Please refer to each coverage form to determine which terms are defined. Words shown in quotations on this endorse- ment may or may not be defined in all coverage forms. SCHEDULE Person or Entity: Any person or organization to whom you are obligated by valid written contract to provide such coverage. Additional Premium: $ (Check box if fully earned.®) Included WHO IS AN INSURED is amended to include the person or entity shown in the Schedule above as an Additional Insured under this insurance, but only as respects negligent acts or omissions of the Named Insured and only as respects any coverage not otherwise excluded in the policy. Our agreement to accept an Additional Insured provision in a contract is not an acceptance of any other provisions of the contract or the contract in total. When coverage does not apply for the Named Insured, no coverage or defense shall be afforded to the Additional In- sured. No coverage shall be afforded to the Additional Insured for injury or damage of any type to any "employee" of the Named Insured or to any obligation of the Additional Insured to indemnify another because of damages arising out of such injury or damage. All other terms and conditions remain unchanged. MEGL 0009-01 04 11 Includes copyrighted material of Insurance Services Office, Inc. Page 1 of 1 with its permission. P000000766/C000029976-007/040-"VIP-A00766 /SEL/3 PERSONAL AUTOMOBILE Offer To Renew Declaration effective POLICY DECLARATION Nov 5, 2016 Your coverage expires Nov 05, 2018, at 12:01 A.M. Payment of the premium renews your policy for the period shown. If your payment is not received before Nov 05, 2018 this Offer to Renew will be null and void. pill 1111 a 1111 r wr. ERIC GREENBERG WAWANESA INSURANCE 18560 VANOWEN ST #14 9050 FRIARS RD STE 101 RESEDA CA 91335 SAN DIEGO CA 92108-5865 Telephone: 1.800-640-2920 Policy Number Account Number 11345100 2174251-1 Named Insured's Phone Number: 818-344-8332 Policy Period 12:01 A.M. standard time at the address of the From Nov 5, 2018 to May 5, 2019 Named Insured as stated herein Named Insured's Email Address: info@libertycityent.com Your 6 month premium for two (2) vehicle(s) is $1,435.99. Refer to the breakdown of premiums below. Description of Owned Vehicle(s) Vehicle A Year N Make Model Vehicle Identification Number Premium per Vehicle ($) 1 2009 1 Honda FIT JHMGE88229SO59233 567.14 2 2013 I Hyundai ELANTRA GLS/ELANTRA 1 KMHDH4AE4DU952103 868.85 LIMITED Premium Subtotal for Vehicles 1435.99 Insurance is provided only with respect to the coverage's for which a Premium is stated, subject to all conditions of the policy. Coverage and Limits of Liability See Policy for Coverage Details Bodily Injury Liability $15,000 per person/$30,000 each occurrence Property Damage Liability $5,000 each occurrence ................... Medical Payments $5,000 each person Comprehensive $500 deductible Collision $500 deductible Uninsured/Underinsured Motorists Protection $30,000 per person/$60,000 each occurrence Uninsured Motorists Collision Deductible Waiver Premiums per Vehicle ($) 1 2 175.06 274.94 112.55 192.63 27.92 40.61 ......... 21.83 20.36 188.86 281.42 Total Premium per Vehicle ($) All premiums listed are for the full 6 month term, 39.31 57.28 1.61 1.61 567.14 668.65 Oct 05, 2018 00:15 CT "Wawanesa Insurance" is a trademark of Wawanesa General Insurance Company WWMW E*rW1nff*M C aft Event Indu" T'Y May 9, 2018 To Whom It May Concern, Liberty City contracts our various performers on an "as needed" basis for individual events rather than hiring individuals as employees. All of the performers are independent contractors responsible for their own taxes. Since we have no employees we do not provide workman's compensation. If in the future I hire employees, I will obtain worker's compensation and notify . Sincerely, Eric Greenberg 18560 Vanowen St. #14 • Reseda, CA 91335 • office: 818-344-6929 - fax: 818-344-6108 www.Iibertycityent.com