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PROOF OF INSURANCE (2020) CLOSEDA4 Rm 0CERTIFICATE OF LIABILITY INSURANCE DATE(MMaDDtYYYY) L I 05/02/2019 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 rovisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may requlire 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 Merchandising K&K Insurance Group, Inc. M, Noy Exl). 1-800-328-2317 FAX NII: 1-260-459-5502 1712 Magnavox Way E-MAIL info@eventinsurance-kk.com Fort Wayne IN 46804 ADDRESS: PRODUCER CUSTOMER BD: INSURER(S) AFFORDING COVERAGE NAIL R INSURED 2001110142 CP# 114 INSURER A: Nationwide Mutual Insurance Company 23787 Tropic Starr I INSURER B: DBA: TropicStarr I INSURER C: ` 341 N. Stevens St. I INSURER D: Orange, CA 92868 I INSURER E: A Member of the Sports, Leisure & Entertainment RPG I INSURER F: COVERAGES CERTIFICATE NUMBER: 2000417751 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 i ADDL SUBR TYPE OF INSURANCE POLICY NUMBER POLICY EFF POLICY EXP LIMITS I LTR I INSR wVD (MM/DD/YYYI() (MMI/DD/XYY`n AX COMMERCIAL GENERAL LIABILITY X 6BRPG0000007005500 05/04/19 05/04/20 EACH OCCURRENCE $1,000,000 I CLAIMS -MADE OCCUR X 12:01 AM 12:01 AM DAMAGE To RENTED I $1,000,000 PREMISES (Ea Occurrence) MED EXP (Any one person) Excluded PERSONAL & ADV INJURY Excluded - GEN'LAGGREGATE LIMIT APPLIES PER: I GENERAL AGGREGATE $5,000,000 I�POLICY 0 PROJECT 0 LOC PRODUCTS — COMP/OP AGG $1,000,000 OTHER: PROFESSIONAL LIABILITY LEGAL LIAB TO PARTICIPANTS $1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMI'i(Ea accident) ANY AUTO nDILY INJURY (Per person) OWNED SCHEDULED AUTOS ONLYAUTOS BODILY INJURY (Per accident) HIRED H NON -OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) X Not provided while in Hawaii I UUMMBBRELLA OCCUR EACH OCCURRENCE LIAB H CLAIMS -MADE AGGREGATE �EXCESS I DED n RETENTION WORKERS COMPENSATION N/A AND EMPLOYERS' LIABILITY _JPER STATUTELIOTHER ANY PROPRIETOR/PARTNER/ Y / N E L EACH ACCIDENT EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L, DISEASE— EA EMPLOYEE If yes, describe under E L DISEASE— POLICY LIMIT DESCRIPTION OF OPERATIONS below I, A MEDICAL PAYMENTS FOR PARTICIPANTS 05/04/19 05/04/20PRIMARY MEDICAL $5,000 6BRPG0000007005500 12:01 AM 12:01 AM M i EXCESS MEDICAL DESCRIPTION OF OPERATIONS / LOCATIONS/ VEHiLES (.,CORD 101, Additional Remarks Schedule, maybe attached if more space is required) Type of Group: Musicians, singers or vocalists; Music Genre: Big band, Blues, Country, Ethnic/world, Jazz, Oldies, Pop/soft rock, R&B, Swing; Type of Venue: Auditoriums, Outdoor venues, Reception halls City of EI Segundo, its officers, employees, agents and volunteers are added as an additional insured, but only for liability caused, in whole or in part, by the acts or omissions of the named insured. ***This certificate voids and replaces certificate # W01426673*** a CERTIFICATE HOLDER CANCELLATION City of EI Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE 350 Main 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 ,X� 1968,2015 ACORD CORPORA'TIO'N. All rights reserved. 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: 6BRPG0000007005500 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, its officers, employees, agents and volunteers 350 Main Street EI Segundo, CA 90245 Named Insured: Tropic Starr DBA: TropicStarr CP# 114 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 B. With respect to the insurance afforded to these additional insureds, additional insured the person(s) or organization(s) shown in the the following is added to Section III — Limits Of Insurance: Schedule, but only with respect to liability for "bodily injury", If coverage provided to the additional insured is required by a "property damage" or "personal and advertising injury" caused, in contract or agreement, the most we will pay on behalf of the whole or in part, by your acts or omissions or the acts or omissions additional insured is the amount of insurance: 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. 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 © Insurance Services Office, Inc., 2012 Page 2 of 2 X,r apa thip e a41d,; I1,'ar dy.41n yviN p'p ove compeaY ient,. IN °Raa°alCel , p nd u:ltalrraalct Us aru4llvulne ° oul have da Iq ulna Oon 1011 uvlru M W If4eIprv, A c'lli:nillv'll.. V yuv'u',v ha'v ii, as dapu'Iv w0l Balt you ba* Icmi Ow mad as souvro ;as p'�u:aa.sig"ulla, And IrNe yo u'IVN allays, have a cha sir.0 vd.merp IMO replllaaul Your m'nakviiM°6u I,I v uv'folu Isla a »Illlopy in Irvllur p!eapplluMvved usemod;.,'voa l ll gua antusat,a yoll.ly Ilvpaiiz f yr ray Il,vu'uly as you II°fluoro uvuUe6 se Your a~urg,.lu'de, Thank you for chloasing Progressive. IE YOUR III 411I dECiCftINNIaIMI I... I�;cluPo hlr IId1e t,eelmu;„ INsaNOl�ksra� M�awYu, I IuvuaGd;aasllu IIS.."uR lull rc.�aN �Bnr p'mrNr.ii•,,,uuX r iu,Nn„uuv!sa uIYN d:�uiiu°uP�I:ou!u'llYaallllramo . pull I'r''wcauOm�i^'a ;�uw^u;v wp,dll'uo. �u�ui�r��:rN, II'R;P IINIE';ulN,AT eA IiI.II.DN'I'!O UR O; 0 d..ICVVaI'IN ;.k d It 4499 wa q,'?m mu,o n';Ilgamna'. N'arrmg; q,l„,;,I' 'tl” ,ci?NIYu. KEEP THIS CARD 18 YOUR VEHICLE WMLJE IN OPEMTION. , 111 "SIIIIR,IINICE IIIIICWEICIIUI:11110 TION 'CM CafiffaICIM'Illuk Pol'iq Nlannaher. M'+5"nRI9.1F^ 'G NAIC nWu,rOmbve Ifs°W Effective Date. ExpkafiomO3te.(11312d'2a'I;2.Iy Polity' Typc. IwMrmoj.tfl Illlcranurm Il vo..pvl"$0 m wg"'<S Ilrru,4 'I NpI,PU I!i>'^;11IE y P.IfN. Hlal!m 94"Y'3!1,I EpuvOor4 SM IW Im'1 Named IumawmpdK,,91. MOD NOWAA MN m. NUMDIIK,8RA IaO& MWIC STAR Year IIIPo'al1w, madiak V1�I 20,'Jrl ICIYINE'MI:11 W'IrOBSl(1,2WI bG1clv4ku5M0N11'9'I,Y$a&VI Your pdky meeft tM requiremeffasof SwcOon t & 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. (_) 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 # 4 1 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 g y ppp yPoprovisions o he agreement will automatically become void. Signature of A lica g immediate) com r DatePrint Name a WIb m `IDACNP1,JMJ} Agreement for: -,VAAJ �AUMOJA Dated: r w' Reviewed by: