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PROOF OF INSURANCE (2019) CLOSEDN,0 DATE(MM/DD/YYYY) A4C0P L> CERTIFICATE OF' LIAISILITY INSURANCE 02/04/2019 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 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 HCC Specialty PHONEIIItu I ): r r. 401 Edgewater Place, Suite 400ADDRESS: -Wo but't's.. Wakefield, MA 01880 ) $im ^^ INSURER(S) AFFORDING COVERAGE NAIC # INSURED INSURERA: New„H„a„n1Sf)Ife Ii1SUr8nCe COmpBrly 23841 James Fernando Pou INsuRERe: United States Fire lnsuran,cComPany.. 21113e mmmmm 709 Briarwood Lane INSURERC: San Diego, CA 91773 INSURERD: INSURER E : p INSURER F : 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. tiro TYPEOFINSURAN E I OL q SUBA WVD POLICYNUMBER (fMM/DD/VYXY) MIN/IDD/YYYYI X ^ LIMB C .............................................. S GENERAL LIABILITY EACH OCC URRENCE $ 1,000,000 A SEL065468199 X 02/07/2019 07/03/2019 ”) 5�� COMMERCIAL GENER L CLAIMS -MADE oOCCURX 30m5^ mOmpo X Host Liquor PERSONAL BADV INJURY $ 1,000,000 B X Medical Expense US 1104119 02/07/2019 07/03/2019 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS -COMP/OP AGG $ ,000,000 .X.,u (...... I JEF18' � „ m $ .1 ............. POLICY LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ -- (Ea accident) ANY AUTO BODILY INJURY (Per person) $_...................... ___.. ALL OWNED AUTOS BOD....................................................................._..... ILY INJURY (Per accident) $ SCHEDULEDAUTOS ROPE deotDAMAGE...........�............$ .............. PROPERTY HIRED AUTOS NON -OWNED AUTOS$ ........................................................ ..... $ UMBRELLA LIAB I OCCUR EACH OCCURRENCE $ ........... EXCESS LIAB AGGREGATE $ DEDUCTIBLE $. ......_ .......................................... RETENTION $ $ WORKERS COMPENSATION Yr 251 N Y V- u i ZQAX d IMITS I _FP AND EMPLOYERS' LIABILITY Y / N _,,,,,,,, ANY PROPRIETOR/PARTNER/EXECUTIVE E, L, EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ (Mandatory In NH) E-1- DISEASE - EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E., L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) The Certificate Holder is added as Additional Insured with respects to our Insured's operations only, This insurance is primary and non-contributory as required by written contract, This coverage is with respect to Summer Concert in the Park event to be held 06/30/2019 - 06/30/2019 at Library Park EI Segundo CA CERTIFICATE HOLDER CANCELLATION City of EI Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED 350 Main Street IN ACCORDANCE WITH THE POLICY PROVISIONS. EI Segundo, CA 90245 AUTHORIZED REPRESENTATIVE ACORD 25 (2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. POLICY NUMBER: 65468199 COMMERCIAL GENERAL LIABILITY CG 201104 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - MANAGERS OR LESSORS OF PREMISES This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Designation Of Premises (Part Leased To You): City of El Segundo 350 Main Street EI Segundo CA 90245 Name Of Person(s) Or Organization(s) (Additional Insured): City of EI Segundo 350 Main Street El Segundo CA 90245 Additional Premium: Included information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section It — 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 arising out of the ownership, maintenance or use of that part of the premises leased to you and shown in the Schedule and subject to the following additional exclusions: This insurance does not apply to: 1. Any 'occurrence" which takes place after you cease to be a tenant in that premises. 2. Structural alterations, new construction or demolition operations performed by or on behalf of the person(s) or organization(s) shown in the Schedule. 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 110413 0 Insurance Services Office, Inc., 2012 Page 1 of 1 POLICY NUMBER: 65468199 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): As submitted to company and required by written contract. 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 . owever: 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 111— 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 0413 0 Insurance Services Office, Inc., 2012 Page 1 of 1 ATTACHMENT # 1 James Fernando Pou Requested Effective Date: Feb 07, 2019 1) Event Name and Location: Summer Concert in the Park Library Park 600 Block of Main Street EI Segundo, CA 90245 Event Date: Jun 30, 2019 Class and Option: Class 1, Option 1 Rate: 8.00 % of primary GL premium (no minimum premium) Premium: $4.00 GA27037 Attachment h "'..""'"• � �m�w�Yl�w'"'"Y�r...mN�lullllw r I u'IY I n III PII VI III M II ,,; IIIIIIIp�Ip4', 1 pl m I V, uolllYulhlllu Illllllllli ud�01��1 I„! p lum sa II "P ' IIII r I'I IIIIIIIIII 'm''. 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A pp All .L� 4)LAJ IF- -4-1 Oop—1 4.0 -�-jI a AZ CL Co C'""'� 3C., iII w 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 Name of Agent Policy Number Expiration Date Phone # U I 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 thew rs° compensation provisions of Labor Code § 3700 1 must immediately comply with tho e r isio r he ement will automatically become void. q Signature of Applicant Date Print Name 6)U Ri .;r 4 Agreement for: dim c ttwn4 Dated:�J Reviewed by: