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PROOF OF INSURANCE (2019 - 2020) CLOSEDACORD,. CERTIFICATE OF LIABILITY INSURANCEDATo /31/19 1 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION "i ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. FOR SERVICE CALL: THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE FRANCIS L. DEAN & ASSOCIATES OF FLORIDA, LLC COVERAGE AFFORDED BY THE POLICIES BELOW. OCALA, FLORIDA COMPANIES AFFORDING COVERAGE 877/671-3326 www.fdeanfl.com COMPANY RIVERPORT INSURANCE COMPANY _ _ A INSURED SPORTS AND REC, PROVIDERS ASSN, PURCHASING GROUP ....................................... COVERAGES 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. CO POLICY EFFECTIVE POLICY EXPIRATION LTR, TYPE OF INSURANCE POLICY NUMBER„ DATE(M MIDDIYY). DATE IMMIDDIYY) LIMITS GENERAL LIABILITY GENERAL AGGREGATE $ 2,000,000.00 A X COMMERCIAL GENERAL LIABILITY CLAIMS MADE [X] OCCUR FLDG 180488 OWNER'S & CONTRACTOR'S PROT INCLUDES ATHLETIC PARTICIPANTS AUTOMOBILE LIABILITY ANY AUTO _ ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS GARAGE (LIABILITY ANY AUTO EXCESS LIABILITY UMBRELLA FORM OTHER THAN UMBRELLA FORM m WORKER'S COMPENSATION AND EMPLOYERS' LIABILITY THE PROPRIETOR/ INCL PARTNERS/EXECUTIVE EXCL ...................... PRODUCTS-COMP/OP AGG $ 2,000,000.00 ............................... _.. 05/31/19 05/31/20 PERSONAL & ADV INJURY $ 1,000,000.00 EACH OCCURRENCE $ 1,000,000.00 FIRE DAMAGE (Any one fire) $ 300,000.00 MED EXP (Any one person) $ 5,000.00 COMBINED SINGLE LIMIT BODILY INJURY (Per person) BODILY INJURY (Per accident) PROPERTY DAMAGE COMPANY Memphis Music Group, Inc. B 24534 New Haven Drive COMPANY Murrieta, CA 92562 C CERT. #SO146616-00 COMPANY EACH OCCURRENCE D ....................................... COVERAGES 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. CO POLICY EFFECTIVE POLICY EXPIRATION LTR, TYPE OF INSURANCE POLICY NUMBER„ DATE(M MIDDIYY). DATE IMMIDDIYY) LIMITS GENERAL LIABILITY GENERAL AGGREGATE $ 2,000,000.00 A X COMMERCIAL GENERAL LIABILITY CLAIMS MADE [X] OCCUR FLDG 180488 OWNER'S & CONTRACTOR'S PROT INCLUDES ATHLETIC PARTICIPANTS AUTOMOBILE LIABILITY ANY AUTO _ ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS GARAGE (LIABILITY ANY AUTO EXCESS LIABILITY UMBRELLA FORM OTHER THAN UMBRELLA FORM m WORKER'S COMPENSATION AND EMPLOYERS' LIABILITY THE PROPRIETOR/ INCL PARTNERS/EXECUTIVE EXCL ...................... PRODUCTS-COMP/OP AGG $ 2,000,000.00 ............................... _.. 05/31/19 05/31/20 PERSONAL & ADV INJURY $ 1,000,000.00 EACH OCCURRENCE $ 1,000,000.00 FIRE DAMAGE (Any one fire) $ 300,000.00 MED EXP (Any one person) $ 5,000.00 COMBINED SINGLE LIMIT BODILY INJURY (Per person) BODILY INJURY (Per accident) PROPERTY DAMAGE $ AUTO ONLY -EA ACCIDENT $ OTHER THAN AUTO ONLY U EACH ACCIDENT $ AGGREGATES EACH OCCURRENCE $ AGGREGATE $ ETH'..................... TORYTLIMITS I_...I ER Y EL EACH ACCIDENT $ EL DISEASE- POLICY LIMIT $ 1111((( OFFICERS ARE: EL DISEASE - EA EMPLOYEE $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS THE CERTIFICATE HOLDER IS ADDED AS AN ADDITIONAL INSURED BUT ONLY WITH RESPECT TO LIABILITY ARISING OUT OF OPERATIONS OF THE NAMED INSURED DURING THE POLICY PERIOD, Band Activities ERT F C I KATE HOLDER City of EI Segundo, it's officers, officials, employees, agents and volunteers. Recreation Park 401 Sheldon St EI Segundo, CA 90245 ACORD 2" (1195) CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. VES. AUTHORIZED REPRESENTATIVE Francis L. Dean © ACORD CORPORATION 1988 POLICY NUMBER: FLDG 180488 COMMERCIAL GENERAL LIABILITY CG 20 51 30 19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. - v40 i "9111 1WIM, e I 4ko lu 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, officials, employees, agents and volunteers Location(s) Of Covered Operations Recreation Park 401 Sheldon St EI Segundo, CA 90245 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: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) desig- nated above. B. With respect to the insurance afforded to these additional insureds, the following additional exclu- sions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equip- ment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its in- tended use by any person or organization oth- er than another contractor or subcontractor engaged in performing operations for a prin- cipal as a part of the same project. CG 20 51 30 19 Page 1 of 1 Fax recipient information To: Fax #: Number of pages faxed: 2 ORIME'Insurincce Policy Number: 927805268 Underwritten by: Progressive West Ins Co Policyholder: Neil Morrow June 3, 2019 Page 1 of 1 1-951-200-5655 The Insurance Store Contact your agent for personalized service. Here are the policy documents you requested Verification of lns....,....e.................................... ................... .............. „ ,,,,,,, ., ,, • urance Thank you for choosing Drive Insurance. Drive Insurance offers several convenient service options: • Contact your agent for personalized service and counsel when you are thinking about making changes to your policy. • Visit Drivel nsurance.com 24 hours a day to view and print policy documents, quote a change to your policy, update policy information, and view claims information. While on Drivel nsurance.com be sure to provide us with your e-mail address to receive reminders about upcoming payments, transaction confirmations, and claims instructions. • Call our Customer Service number, 1-800-300-3693, to make or confirm payments over the phone, order ID cards and Declarations pages, and more. The Insurance Store 40810 COUNTY CTR #120 TEMECULA, CA 92591 NAIC Company Code: 27804 Verification of Insurance for Neil Morrow DRIME®/nsurance Policy Number: 927805268 Underwritten by: Progressive West Ins Co Policyholder: Neil Morrow Page 1 of 1 June 3, 2019 The Insurance Store 1-951-200-5655 Contact your agent for personalized service. Customer Service 1-800-300-3693 24 hours a day, 7 days a week This verification of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policies listed herein. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this verification of insurance may be issued or may pertain, the insurance afforded by the policies described herein is subject to all the terms, exclusions and conditions of the policies. Please accept this letter as verification of insurance for this policy. Policy and driver information ........................................................................................................ Policy number: ...................................... 927805268 ........................................................................................................................................... Policy state: .. California .............................................................................................................................................. Policy period: Mar 2, 2019 - Sep 2, 2019 ......... ............................... ................................................................................................... There was no lapse in coverage during this policy period. ........................................................................M.a"y ..................................................................... . Effective date: .....................May 29,.201.9................. Drivers: Neil Morrow Insured Driver Jerelyn C Morrow .................................................................................................................. .. .. ........................... Address: 24534 New Haven Dr Murrieta, CA 92562 Vehicle information Vehicle: 2015 Ford Flex Limited .................................................................................. Vehicle identification number: 2FMGK5D82FBA09338 Lienhold er:..,.., ,. CAR MAX AUT0ANANCE.......... PO Box 440609 KENNESAW, GA 30160 Coverage information Bodily Injury Liability: $100,000 each person/$300,000 each accident Property Damage Liability: $50,000 each accident ,,............................................................... ........ Collision: Deductible: $500 deductible ........................................................................................................................................ Comprehensive: Deductible: $250 deductible Form Vol (07/13) 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: L_) 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 # CN 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 the workers' compensation provisions of Labor Code § 3700.1 must immediately comply with tse: sions or the agreement will automatically become void. Signature of Applicant f Date 4-13-19 Print Name eel Morrow Agreement for: �Abmft I is MM& Dated: / Reviewed by: 03