Loading...
PROOF OF INSURANCE (2020) CLOSEDDATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 05/16/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON' 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 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 818 tt407-5:300..............................................._.... � ..:..�ONfMEt6 m.._ JUC N�................. ...... .: 9620 Krouse Canuon Place, Unit Services, Inc. .L. " 81. � � NAME: ....4t�'7,-,5,�8 Chatsworth, CA 9131'1 PPMAP............. cu tomerservice krouseins...co S1 AFFORDING COVERAGE ................. NAIC # INSURERI Phone No. (818)m,407-5300 ,Fax No. (818) 4Q :5308 INSURER A : NAS - North American_ Specialty Insurance Compa,n,Lr„ 2,9874 INSURED INSURER B: EL SEGUNDO ART WALK, LLC 763 MAIN STREET EI Segundo, CA 90245 INSURER C: INSURER D : INSURER E Phone No. (213) 804-0044 Fax No. INSURER F: COVERAGES CERTIFICATE NUMBER: 813278 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. NAS ,. _... COMMERCIAL LIABILITY IN OLSD WVD EKG8022500-01 06/01 /2019 06/01/2020 EACH OCCURRENCE Rh)t LIMBS LTR TYPE COMME POLICYNUMBER DrCCM (MM/DDIYYYY) 2....,,,,....� CLAIMS -MADE � OCCUR X X DAMAGE SESBErtNtt",An...,..... $ 1.O,w....,OOi� ) 00 PREMI $ 100.,.900 I X Host Liouor ELqr,,,(1.0'00.000AggJQLcc) GE N'L AGGREGATE LIMIT APPLIES PER: h A a POLICY ❑ JE T 7 LOC 7 OTHER: NAS AUTOMOBILE LIABILITY ANY AUTO .m..--... .............. OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY NAS UMBRELLA LIAB �(^ OCCUR X EXCESS LIAB _ CLAIMS -MADE _..._.., w ............................ DED Y RETENTION $ WORKERS COMPENSATION AND EMPLOYERTLIABILITY YIN ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBEREXCLUDED? N/A (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below MED EXP (Any one person) $ 5 000 PERSONAL & ADV INJURY ,$ 1,000,00& ,GENERALAGGREGATE $ 2000,000' PRODUCTS-COMP/OPAGG ................. I EKA8002279-01 06/01/2019 coMBINEo�INGLELIMUT $ 06/01 /2020 Ea acclul...�....��......... 1,,000 OO ._-... BODILY INJURY (Per person) $ Included uded BODILY INJURY (Per accident) $ Included AMAGEM. A $ Excluded tPerOeec�- nn� ern^ µ.'.......,. EX�,IV9�Gd $ EKX8004000-01 06/01/2019EACH OCCURRENCE $ 1.0000 AGGREGATE 000000 $ a OTH- J_PER _STATUTE I........,,, E.L. EACH ACCIDENT ,$ E L. DISEASE - EA EMPLOYEE $ E.L. DISEASE -POLICY LIMIT $ NAS Inland Marine EKN8004768-01 06/01/2019 N 06101/2020 See Attached DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES Coverage Location: United States & Canada Covered Events As Declared to and Accepted Certificate holder is named as additional insured and loss payee as their interest may appear. Coverage by Carrier is primary and non-contributory. All coverages expire at 12:01 a.m. Standard Time. " The actual event dates may be limited. Please review the Scheduled Events farm attached to this certificate. CERTIFICATE HOLDER CANCELLATION CITY OF EL SEGUNDO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ATTN: OFFICERS,OFFICIALS,AGENTS AND THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN EMPLOYEES ACCORDANCE WITH THE POLICY PROVISIONS. 350 MAIN STREET EL SEGUNDO, CA 90245 AUTHORIZED REPRESENTATIVE United States Of America lPhone No. I Fax No. ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD This certificate of insurance does not affirmatively or negatively amend, extend, or alter the coverage afforded by the insurance policy. POLICY NUMBER: EKG8022500-01 COMMERCIAL GENERAL LIABILITY CG 2012 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - STATS: OR GOVERNMENTAL AGENCY OR SUBDIVISION OR POLITICAL SUBDIVISION - P'E'RMITS OR AUTHORIZATIONS 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 EL SEGUNDO OFFICERS, OFFICIALS, AGENTS AND EMPLOYEES, 350 MAIN STREET EL SEGUNDO, CA 90245 N 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 any state or governmental agency or subdivision or political subdivision shown in the Schedule, subject to the following provisions: 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. 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. 2. This insurance does not apply to: a. "Bodily injury", "property damage" or "personal and advertising injury" arising out of operations performed for the federal government, state or municipality; or b. "Bodily injury" or "property damage" included within the "products -completed operations hazard". 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 12 0413 ©insurance Services Office, Inc., 2012 Page 1 of 1 ADDITIONAL COVERAGE DETAILS INSURED EL SEGUNDO ART WALK, LLC The following is attached to and made part of certificate number 813278. Policy Details Coverage Limit Inland Marine Company: North American Specialty Insurance Company Policy Number: EKN8004768-01 "Period: 06/01/2019 - 06/01/2020: 366 Day(s) DATE (MM/DDNY) 05/16/2019 Deductible General Aggregate Equipment, props, sets, wardrobe (rented) Excluded 1,000,000 Equipment, Props, Sets, Wardrobe (owned) Excluded Each Occurrence Rented Furs, Jewelry, Art & Antiques Coverage Excluded 100,000 Extra Expense Excluded Blanket Additional Insureds (other than city/special certs & Third Party Property Damage 1,000,000 2,500 Office Contents Excluded Waiver of Subrogation Business Income/Extra Expense Excluded Excluded Hired/Non-Owned Physical Damage -Aggregate Excluded Host Liquor Hired/Non-Owned Physical Damage -Per Vehicle Excluded 1,000,000 Rental Cost Reimbursement Excluded I EDP EDP (Electronic Data Processing Equipment) Excluded Limited Computer Trus Coverage Excluded Accounts Receivable Excluded Valuable Papers and Records Excluded Money & Securities Excluded Waiver of Subrogation Excluded Coverage Extension Endorsement Coverage Extension Endorsement Excluded Worldwide Coverage Excluded Terrorism Included General Liability Company: North American Specialty Insurance Company Policy Number: EKG8022500-01 'Period: 06/01/2019 - 06/01/2020: 366 Day(s) General Aggregate 2,000,000 Products / Completed Operations 1,000,000 Personal /Advertising Injury 1,000,000 Each Occurrence 1,000,000 Fire Legal 100,000 Medical Payments 5,000 Blanket Additional Insureds (other than city/special certs & Included waivers) City / Other Special Certificates Included Waiver of Subrogation Included Employee Benefits Liability - Policy Aggregate Excluded Employee Benefits Liability - Each Claim Excluded Host Liquor Included Liquor Liability -Aggregate 1,000,000 Liquor Liability -Each Common Cause Limit 1,000,000 Abuse & Molestation -Aggregate Excluded APM-CERT-DETAILS 1009 Certificate Number 813278 Policy Details Coverage Limit Deductible Abuse & Molestation -Each Claim Excluded Terrorism Included *All coverages expire at 12:01 a.m. Standard Time. APM-CERT-DETAILS 1009 Certificate Number 813278 Certificate Number: 813278 Event Type EL SEGUNDO ART WALK 2019 Art Shows Venue PARKING LOT 314 MAIN STREET EL SEGUNDO, CA 90245 Scheduled Events Dates 06/19/2019 - 06/20/2019 at 12:01 am (Setup) 06/20/2019 - 06/21/2019 at 12:01 am Attendees 50 Participants 2,500 Spectators ABANEV SCHD(05/06) Page 1 of 1 Certificate Number: 813279 Event Type EL SEGUNDO ART WALK 2019 Art Shows Venue PARKING LOT 314 MAIN STREET EL SEGUNDO, CA 90245 Scheduled Events Dates 07/17/2019 - 07/18/2019 at 12:01 am (Setup) 07/18/2019 - 07/19/2019 at 12:01 am Attendees 50 Participants 2,500 Spectators ABANEV-SCHD(05/06) Page 1 of 1 Certificate Number: 813280 Event Type EL SEGUNDO ART WALK 2019 Art Shows Venue PARKING LOT 314 MAIN STREET EL SEGUNDO, CA 90245 Scheduled Events Dates 08/14/2019 - 08/15/2019 at 12:01 am (Setup) 08/15/2019 - 08/16/2019 at 12:01 am Attendees 50 Participants 2,500 Spectators ABANEV SCHD(05/O6) Page 1 of 1 SCHEDULE OF FORMS Insured: EL SEGUNDO ART WALK, LLC DATE (MM/DD/YY) 05/16/2019 This Schedule of Forms is attached to and made part of certificate number 813278, as of 05/16/2019 at 01:52 PM PT, and lists the forms included in the policy(s) and subsequent endorsement (s) at the time this certificate was issued. Form # Inland Marine Policy Inland Marine Notices SP5369 NAS-GLB-NOTICE Forms NAS-ABIM-DEC NAS-ABF-SCH NAS-NI-SCH NAS -LS -EXT NAS -AB -CPC NAS-ABTPD-POL NAS -AB -003 NAS -AB -725 NAS -AB -711 CLO162 IM2009 CL0600 SP4161 SP6069 SP5694 SP3881 Liability Policy General Liability Notices SP5369 NAS-GLB-NOTICE Forms NAS-ABGL-DEC NAS-ABF-SCH NAS-NI-SCH NAS -LS -EXT NAS -AB -220 NAS -AB -214 NAS -AB -219 NAS -AB -007 CG0001 IL0017 NAS -AB -003 NAS -AB -416 NAS -AB -432 NAS -AB -436 NAS -AB -411 NAS -AB -402 CG2011 CG2001 CG2012 CG2028 CG2026 CG2013 CG2404 NAS -AB -006 NAS -AB -600 NAS -AB -417 NAS -AB -205 NAS -AB -420 CG2147 NAS -AB -433 NAS -AB -208 NAS -AB -434 NAS -AB -404 NAS -AB -426 NAS -AB -405 NAS -AB -410 NAS -AB -408 NAS -AB -419 NAS -AB -424 NAS -AB -403 Ed. Name 0514 SwissRe Front Jacket 0901 Privacy Notice and Disclosure 0808 Commercial Inland Marine Declarations 0608 Schedule of Forms 0101 Named Insured Schedule 0101 Location Schedule 1008 Common Conditions, Definitions and Exclusions 0608 Third Party Property Damage Coverage Form 0608 Minimum Premium Endorsement 0608 Loss Payable form 1109 Excluded Property Endorsement 0116 Amendatory Endorsement - California 0112 Amendatory Endorsement - California 0115 Certified Terrorism Loss 0115 Exclusion of other than Certified Acts of Terrorism 0115 Disclosure pursuant toTRIA 1012 International Trade or Economic Sanctions 0307 Signature Page 0514 SwissRe Front Jacket 0901 Privacy Notice and Disclosure 0109 Commercial General Liability Declarations 0608 Schedule of Forms 0101 Named Insured Schedule 0101 Location Schedule 0613 Annual Event Rating Schedule 0613 Concessionaire/Exhibitor Rate Endorsement 0613 Additional Insured Rating Schedule 0909 Schedule of Events 0413 Commercial General Liability Coverage Form 1198 Common Policy Conditions 0608 Minimum Premium Endorsement 0608 Event Limitation Endorsement 0608 Employee Defined 0608 Communicable Disease Exclusion 0608 Unscheduled Products Limitation Endorsement 0908 Additional Insured - Owners or Lessees, Scheduled Person or Organization (Primary and Noncontributory endorsement) 0413 Additional Insured - Managers of Lessors of Premises 0413 Primary and Noncontributory - Other Insurance Condition 0413 Additional Insured - State or Governmental Agency or Subdivision or Political Subdivision - Permits or Authorizations 0413 Additional Insured - Lessor of leased equipment 0413 Additional Insured - Designated Person or Organization 0413 Additional Insured - State or Governmental Agency or Subdivision or Political Subdivision - Permits or Authorizations Relating to Premises 0509 Waiver of Transfer of Rights of Recovery Against Others to Us 0608 Unscheduled Production, Presentation or Event Exclusion 0608 Production Stunt, Pyrotechnic & Animal Exposure Exclusion 0608 Hazardous Activities, Pyrotechnic &Animal Exposure Exclusion 0608 Newly Acquired or Formed Entity Exclusion 0608 Partnership, Joint Venture and Limited Liability Company Exclusion 1207 Employment Related Practices Exclusion 0909 Cross Suits Exclusion 0608 Property Damage to Rented Premises Exclusion 0608 False Arrest, Detention, Imprisonment, Libel, Slander, Right to Privacy, Advertising Idea, Copyright, Trade Dress and Slogan Exclusion 0608 Informational Content Exclusion 0608 Media Content Exclusion 0608 Injury to Participants in Sports or Athletics Activities Exclusion 0608 Rap and Hip -Hop Conditional Exclusion 0608 Moshing Exclusion 0608 Overnight, Outdoor And Temporary Structure Camping Conditional Exclusion 0608 Abuse or Sexual Molestation Exclusion 0608 Assault and Battery Exclusion APA-CERT-FORMLIST 0914 Certificate Number: 813278 Page 1 of 3 SCHEDULE OF FORMS Insured: EL SEGUNDO ART WALK, LLC DATE (MMIDDW) 05/16/2019 This Schedule of Forms is attached to and made part of certificate number 813278, as of 05/16/2019 at 01:52 PM PT, and lists the forms included in the policy(s) and subsequent endorsement (s) at the time this certificate was issued. Form # Ed. Name NAS -AB -209 0608 Total Pollution Exclusion Endorsement NAS -AB -423 0608 Absolute Asbestos Exclusion NAS -AB -425 0608 Lead Contamination Exclusion NAS -AB -428 0608 Fungus, Mildew and Mold Exclusion CG2196 0305 Silica or Silica -Related Dust Exclusion NAS-ABLL-DEC 0101 Liquor Liability Declarations CGO033 0413 Liquor Liability Coverage Forth NAS -AB -221 0613 Liquor Rating Schedule IL0270 0912 California Changes - Cancellation and Nonrenewal Endorsement IL0021 0908 Nuclear Energy Liability Exclusion Endorsement (Broad Form) CG3234 0105 California Changes SP4159 0115 Exclusion of other than Certified Acts SP6069 0115 Disclosure pursuant to TRIA CG2170 0115 Cap on Losses From Certified Acts of Terrorism SP5694 1012 International Trade or Economic Sanctions SP3881 0307 Signature Page Automobile Policy Automobile Notices 0514 SwissRe Front Jacket SP5369 0514 SwissRe Front Jacket NAS-GLB-NOTICE 0901 Privacy Notice and Disclosure Forms 0712 Following Form Commercial Excess Liability Insurance Policy Declarations NAS-NCS-MCA-DEC1 0712 Named Insured Schedule FF00127 0712 Following Form Commercial Excess Liability Insurance Policy NAS-ABF-SCH 0315 Multiple Followed Policy Amendatory Endorsement NAS-NI-SCH 0712 Non -Follow Form of Specified Coverage of Followed Policy FF00098 0712 Lead Exclusion FF00097 0712 Silica Exclusion FF00011CA 0712 California Changes- Cancellation and Nonrenewal NAS -AB -003 0115 Exclusion of Other Than Certified Acts of Terrorism NAS -AB -900 0115 Disclosure pursuant to TRIA NAS -AB -901 0115 Cap on Losses from Certified Ads of Terrorism NAS -AB -902 1012 International Trade or Economic Sanctions IL027D 0307 Signature Page IL0021 SP5694 Excess Liability Policy Excess Liability 0201 0101 0608 0101 0101 1013 1198 0608 0608 0608 0608 0912 0908 0517 1012 0307 Business Auto Coverage Forth NAS-CA-DEC2 Declarations Schedule of Hired or Borrowed Covered Autos Coverage and Premiums Schedule of Forms Named Insured Schedule NAS -LS -EXT Location Schedule CA0001 Business Auto Coverage Form IL0017 Common Policy Conditions Minimum Premium Endorsement Additional Insured -Owners or Lessees, Scheduled Person or Organization Additional Insured -Owners or Lessees, Scheduled Person or Organization (Primary Non -Contributory Endorsement) Waiver of Subrogation California Changes -Cancellation and Nonrenewal Endorsement Nuclear Energy Liability Exclu CA0143 sion Endorsement (Broad Form) ic Sanctions California Changes International Trade or Ewnom SP3661 Signature Page Notices SP5369 0514 SwissRe Front Jacket NAS-GLB-NOTICE 0901 Privacy Notice and Disclosure Forms FF00001 0712 Following Form Commercial Excess Liability Insurance Policy Declarations FF00135 0712 Named Insured Schedule FF00127 0712 Following Form Commercial Excess Liability Insurance Policy FF00171 0315 Multiple Followed Policy Amendatory Endorsement FF00118 0712 Non -Follow Form of Specified Coverage of Followed Policy FF00098 0712 Lead Exclusion FF00097 0712 Silica Exclusion FF00011CA 0712 California Changes- Cancellation and Nonrenewal SP5632 0115 Exclusion of Other Than Certified Acts of Terrorism SP6069 0115 Disclosure pursuant to TRIA SP5629 0115 Cap on Losses from Certified Ads of Terrorism SP5694 1012 International Trade or Economic Sanctions SP3881 0307 Signature Page APA -CERT -FORM LIST 0914 Certificate Number. 813278 Page 2 of 3 DATE (MM/DDIM SCHEDULE OF FORMS 05/16/2019 Disclaimers This certificate of Liability Insurance includes the Type of Insurance, Limits, and Schedule of Forms in effect as of 05/16/2019 at 01:52 PM PT. It does not affirmatively or negatively amend, extend, or alter the coverage afforded by the insurance policy nor confer any rights upon the certificate holder. You may be required to request an updated certificate in the event of subsequent policy modifications. The information included in this certificate that has been provided by Abacus Insurance Brokers, is for your information only, and does not create a contract or agency relationship between the certificate holder or any insured and Abacus Insurance Brokers. By accepting this certificate the certificate holder acknowledges that Abacus Insurance Brokers is not the agent of the certificate holder or any insured, but is solely the agent of the listed carrier(s). Abacus Insurance Brokers makes no representation whether the coverages listed herein are appropriate for the certificate holder or any insured. Please review the listed coverages carefully and direct any questions to your broker. For a complete listing of coverages, terms, conditions and exclusions, please view the referenced Policy(s). APA-CERT-FORMLIST 0914 Certificate Number. 813278 Page 3 of 3 Date (MM/DD/YYYY) Certificate Verification 05/16/2019 Insured: EL SEGUNDO ART WALK, LLC Abacus provides an efficient website lookup tool for certificate holders to verify the authenticity of certificates of insurance. 1. Navigate to the website and input the verification code OR Scan the QR code. 2. The actual certificate issued through the Abacus Platform will download. 3. Compare the details of the downloaded certificate to the certificate presented by the client. Website Verification Code www. abacus. net/verify-certificate 0805HGF6J2 About Certificates Issued through the Abacus.net Platform • Abacus requires that all certificates be issued through the Abacus Platform. Certificates issued outside of the Abacus Platform are invalid. • Certificates may be issued through the Abacus Platform by either the named insured (if registered through the Abacus Platform) or their Abacus registered insurance broker. • Certificates with any stray marks, cross outs or alterations of any sort are invalid. • Each certificate is numbered and correlates to the document issued through the Abacus Platform. APA-CERTVER 0817 Certificate Number: 813278 Page 1 of 1 __... ............ .. 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 # (x) 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 those provisions or the agreement will automatically become void. Signature of Applicant �' Date June 18„ 2019 Print Name George Renffo Agreement for: Dated: Reviewedby: