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PROOF OF INSURANCE (2020) CLOSEDDATE (MM/DD/YYYY) C('Ra CERTIFICATE OF LIABILITY INSURANCE �°" 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 ........... Weiss _4257 Specialty Insurance Agency PHONE Stephanie Is. ._... IAx E-MAIL J I tt),oerts@ certs@specialtyinsuranceagency.com tc.ga�a; 715 246 .......................... Performers of the U.S. _ Ah P.O. Box 24cap69_ ,...,,,,,,,,,,,,, _.,...,......... New Richmond, WI 54017 INSURE")AFFORDING COVERAGE U NAIC/ Evanston Insurance Company 35378 INSURER A : P,, IN S UR E D Eric R. Greenberg INSURER B: dba Liberty City INSURER C: 18560 VanoWen St, Unit 14 .....................^.^....................... Reseda, CA 91335 INSURER D : p INSURER E: f INSURER F: o 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 TYPE OF INSURANCE AWL Suilk . ..... ....... ..... POLICY EFF POLICY EXP LTR POLICY NUMBER IMMADDfYXYYV tMMPDD"YYYY1 LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE$ 1,000,000 X ,.., 300,000 �RINiEr P�°1kCsl:'10 ............,,....,) CLAIMS -MADE OCCUR FRklWIX .ESt(,4i.4r n�frBTRewa,). ..$ MED EXP (Any one person) $ 5,000 ... ......................... ............._ A X X 2CN0165-2490 04/25/2019 04/24/2020 PERSONAL & ADV INJURY g 1,000,000 GENT. AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 0- X POLICY 'JJLCI' LOC .......................... ,P,ROD.UCTS-COMP/OPAGG $ 2,000,000 ..... OTHER. ... $ .... .. AUTOMOBILE LIABILITY I'r COMBINED SINGLE Lw $ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per accident) �$ AUTOS ONLY AUTOS ..PNOPEfiT'"MDAFAGE `$ ". ..... HIRED NON -OWNED AUTOS ONLY AUTOS ONLY �.(P�f.Ad.anll UMBRELLA LIABF OCCUR EACH OCCURRENCE $ EXCESS LIAB V LAIMS MADE AGGREGATE $ II DED 7 � RETENTION $ $ WORKERS COMPENSATION4EL ER OTH- TATUTE_.,_ �. ER„ AND EMPLOYERS' LIABILITY Y / N ............................................_.....__� ANYPROPRIETOR/PARTNER/EXECUTIVE NIA ACH ACCIDENT $ _ ' OFFICERIMEMBER EXCLUDED? (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ If yes describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ A BUSINESS PERSONAL PROPERTY- AGGREGATE $ INLAND MARINE DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 701, Additional Remarks Schedule, may be 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: libertycityeric@aol.com Event Date: Ongoing for policy period CERTIFICATE HOLDER City of EI Segundo 350 Main Street, Room 5 EI Segundo, CA 90245-3813 ACORD 25 (2016/03) 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 AtuflAo";_ W_1� @ 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 2CN0165-2490 COMMERCIAL GENERAL LIABILITY CG 20 12 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ,iT l LUIJN NMI .1.04 pro This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE State Or Governmental Agency Or Subdivision Or Political Subdivision: City of EI Segundo City Clerk Attn: Recreation & Parks Director 350 Main Street, Room 5 EI Segundo, CA 90245-3813 The City of EI Segundo, its officers, officials, employees, agents and certified. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. I' A. Section II — Who Is An Insured is amended to 2. This insurance does not apply to: include as an additional insured any state or a. "Bodily injury", "property damage" or governmental agency or subdivision or political "personal and advertising injury" arising out subdivision shown in the Schedule, subject to the of operations performed for the federal following provisions: government, state or municipality; or 1. This insurance applies only with respect to operations performed by you or on your behalf for which the state or governmental agency or subdivision or political subdivision has issued a permit or authorization. B However: a. The insurance afforded to such additional insured only applies to the extent permitted by law; and b. 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. "Bodily injury" or "property damage" included within the "products -completed operations hazard". 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 12 0413 C Insurance Services Office, Inc., 2012 Page 1 of 1 POLICY NUMBER: 2CN0165-2490 COMMERCIAL GENERAL LIABILITY CG 20 01 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. M611116014:4 WMIRT."I U44:99LON111 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 IRK IV 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: gig 2CN0165-2490 MARKEV 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. P000000390/C000015118.007/038-"VIP-A00390 /SEL/3 ,--.. PERSONAL AUTOMOBILE Offer To Renew Declaration effective MIN POLICY DECLARATION May 5, 2019 IMUMCOYour coverage expires May 05, 2019, at 12:01 A.M. Payment of the premium renews your policy for the period shown. If your payment is not received before May 05, 2019 this Offer to Renew will be null and void. 0 ® e- • 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 Policy Period 12:01 A.M. standard time at the address of the 11345100 2174251-1 From May 5, 2019 to Nov 5, 2019 Named Insured as stated herein Named Insured's Phone Number: 818-344-8332 Named Insured's Email Address: info@Iibertycityent.com Your 6 month premium for two (2) vehicle(s) is $1,145.20. Refer to the breakdown of premiums below. Description of Owned Vehicle(s) Vehicle Year I MakeModel V Vehicle Identification Number Premium per Vehicle ($) 1 2009 Honda C FIT JHMGE88229SO59233 567.14 2 2013 Hyundai ELANTRA GLS/ELANTRA KMHDH4AE4DU952103 -_ 578.06 39.31 LIMITED 1.61 1.61 567.14 I 578.06 Premium Subtotal for Vehicles 1145.20 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/$60,000 each occurrence Uninsured Motorists Collision Deductible _I Waiver Total Premium per Vehicle ($) All premiums listed are for the full 6 month term. Premiums per Vehicle ($) 1 2 175.06 178.61 112.55 120.02 27.92 .................................... - 30.62 21.83 16.99 188.86 187.03 V 39.31 43.18 1.61 1.61 567.14 I 578.06 Apr 04, 201900:23 CT "Wawanesa Insurance" is a trademark of Wawanesa General Insurance Company 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. 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. L_) 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 # (21.5I 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 I must immediately comply with those ovisions the agreement will automatically become void. Signature of Applicant 14,41, -1---1 Date r`a a Print Name r Agreement for: Dated:^-/ Reviewed by:,,....,�-