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PROOF OF INSURANCE (2020 - 2020) CLOSED
aldA6�Z' CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) MAREL' 5/22/2019 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 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 nclA°� cT Stephanie Weiss Specialty Insurance Agency uaTagnetti..............................715-246 8908W........................................................................_............0a.................................... Performers of the U.S. t .tA nth 16Lc Nols 715-246-4257 P.O. Box 24D,,ss: certs@specialtyinsurancea,gency.com New Richmond, WI 54017 INSURER(S) AFFORDING COVERAGE NAIC# INSURER A : Evanston Insurance Company 35378 INSURED Laura D. Caldwell INSURER B: dba ACME Balloon Co. ........................................._............. 12701 Lewis Street, Apt 50 I INSURER C Garden Grove, CA 92840 ( INSURER D: INSURER E : 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. flTsw ADISL UffR LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER POLICY EFF POLICY EXP WMIDDrYYYYI IMMMD/YY'YYI LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 3,000,000 Fx_1 l7rYRE ED 300,000 CLAIMS -MADE OCCUR PREWSESREaoccurrencoU $ --- MED EXP (Any one person) $ 5,000 A X X 2CN0166-20480 04/25/2019 04/24/2020 PERSONAL & ADV INJURY $ 3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ . 5,000, _____•r IX POLICY L_] ,IPEROC'T� LOC L.' PRODUCTS - COMP/OP AGG $ i 5,000,000 .. OTHER. $ AUTOMOBILE LIABILITY I COMBINED SINGLE LIMIT $ IEa acdidenU _ mm ANY AUTO I BODILY INJURY (Per person) $ m OWNEDSCHEDULED I BODILY INJURY $ AUTOS ONLY AUTOS (Per accident) _m HIRED NON -OWNED B PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Wer acddenll $ UMBRELLA LIAB OCCUR �.•_•�...� EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE s DED I I RETENTION $ q s PER WORKERS COMPENSATION .... STA1fUTE,•„_,_,_&. OTH._._ m_----._._._._._.....................� AND EMPLOYERS' LIABILITY Y / N ANYPROPRIETOR/PARTNER/EXECUTIVEE L EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ N/A (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 I VEHICLES (ACORD 101, 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.: Laura D. Caldwell dba ACME Balloon Co. Additional Insured: The City of EI Segundo, its officers, officials, employees, agents, and certified volunteers. Email: SPickens@elsegundo.org Event Date: August 8, 2019 CERTIFICATE HOLDER CANCELLATION The City of EI Segundo 111 West Mariposa Avenue SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE EI Segundo, CA 90245 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD COMMERCIAL GENERAL LIABILITY POLICY NUMBER: III 2CN0166-20480 ARKEV EVANSTON INSURANCE CO IPANY 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. POLICY NUMBER: 2CN0166-20480 COMMERCIAL GENERAL LIABILITY CG 20 10 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. a A, h %,k • •� • This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART Name Of Additional Insured Person(s) Or Organization(s) The City of EI Segundo, its officers, officials, employees, agents, and certified volunteers. SCHEDULE Location(s) Of Covered Operations 111 West Mariposa Avenue 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) designated above. 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 additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equipment 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 intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. CG 20 10 0413 © Insurance Services Office, Inc., 2012 Page 1 of 2 C. 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. Page 2 of 2 © Insurance Services Office, Inc., 2012 CG 20 10 0413 COMMERCIAL GENERAL LIABILITY POLICY NUMBER: III 2CN0166-20480 MARKE. 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. POLICY NUMBER: 2CN0166-20480 COMMERCIAL GENERAL LIABILITY CG 20 01 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. 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 PRODUCER AUTO INS SPECIALISTS -CA 043890 09 PO BOX 6507 ARTESIA, CA 90702-6507 TELEPHONE:IGOO) 493-7879 POLICY NUMBER PICUCII NERK10 0401 09 170241991 -NAMED INSURED PERS64S L1116PhIED BUSTER B CALDWELL DRIVERS BUSTER B CALDWELL LAURA CALDWELL .4 ACALIFORNIA AUTOMOBILE INSILIPANCE COMPANY AUTOMOBILE POLICY DECLARATIONS IMPORTANT COVERAGE EXCLUSION APPLICABLE TO ALL COVERAGES INCLUMNG BUT NOT LIMITED TO, LIABILITY AND UNNSLMED MOTORISTS, PROVIDED NOW OR LATER, 10, h "u,to IhAr 41" Wltl Ctn":i Howofl by qhkt it 1 0 1 n oN! IP44y q' uw a " , " P. V i t, " *m " I'r I . I y, I x V IIP I, 1 1, a, I$ Itiov pw%N *0mooP Nlwn stry,omor a,IhWU tr�i, bvNlo.' t,Wdw. opemited by 3 pman listed kx4ow mtgardle%s .4 who,. the pmpp tN r Is MAOU140 112701 11.1! YVI:S, 311 AIF'l 52,000 ADDRIE:SS 3ARDI:�INI C , 'A 928410t LEASEILOAN GAP COVERAGE "":0.2; Y CA h VEHICLE OEScarp poN SEWAIL NUMBEA COST ORVALUE NtftQ9ZD, PURCH 041f, nP:CM 11 201 1 111( CD% 00TKA LAIStLE SED 40S 11 11:0 N EE98C546507 N 09/2018 2002 ',TOYOTA AVALON SE11I 40R 41 I B1l".`L8ffK2U2353(3 I U 10/2018 q:;, Afflt: I k I n A 110 It AY"" A Aq t A A L NN lld K 1p 641) 0.060 It A I t' A A AND .0, t T (0, 10 N 1% N &: Q�"l I)N'� A o t� w;nt i imu mms vuuo o. n [o.m rk t) wr IaR r i•tlm wwmi. um k v um 11 LP NAVY' ECU PO 80 Zi 110:9LEHIGH VAU..ERA lbo()2 Coverage applies only if premium charge is listed below. Coverage/Limits are subject to all policy terms. COVERAGES LIMITS OF LIABILITY PREMIUMS NON -FACTORY EQUIPMENT CAR1 CAR2 BODILY INJURY LIABILITY $100,000 EACHIRUMON $ 3()0,000 r.ACH A00111THT CAR ITEMS INSURED AND AMOUNTS OF 297 30B INSURANCE FOR EACH ITEM ARE STATED PROPERTY DAMAGE LIABILITY $90,0(j�) VI CIR ACC t,),KN 2132 260 RpAtIN ITEMS INSURED ARE SUBJECT TO UNINSURED MOTORISTSI s I 00. CIO() FAMIPEAGON �, 300.000 EACH•AIZODI:141 95 97 HE DEDUCTIBLE BODILY INJURY UA611LUY UNPNISUPED MOTORISTS S. MAXIMUM ENDORSEMENTS ATTACHED TO THE POLICY PROPERTY DAMAGE UASAITY COULISKM UEDUCTRILE, WAVER MEWCAt EXPENSE 52,000 LEASEILOAN GAP COVERAGE CAR CAIq '`AR REPAIR OR REPLACEMENT GAR CAR COST rOVERACC "'1 "I'tjIl'. III N111 aH,1'trl 1:, � p 11 COMPREHENSIVE Lirnuctt(&.4.,I:Am $500 CAR1 n500 COLLISION 131IOWTHWECAM $500 (:ARl V500 ROADSIDE ASSISTANCE I`;A017 $75 (-AR$75 IFOR TOWtNG SERVICt5l" RENTAL CAR BENEFIT $ 30 PEA DAY 30 DAYS ENDORSEMENTS ATTACHED TO THE POLICY Wommm 13 13 CAn 16 211 c,Pw 4;711 326 CAIR q 4 28 28 PERCAR 2! I C19:ll POLKY11"EF CAUFOPNIA ASSESWNTS CA FRAUD FEE 1,76 CIGA FEE TOTAL PREMIUM 2.276.76 IMPORTANT INFORMATION IF,jE Mcl, L' ,Ils 'Irli tor:,O fotr r V HIS ::N, j,Z: jI.r u." U f W k. R,:* I a()Wo 1 B 1. L I h-. U! 9, 11 1 Pl:, A 1 t "'1 "I'tjIl'. III N111 aH,1'trl 1:, � p 11 �111 app 6 mt, z 1,,,„ f tw,: I t, x pi W 'Y)"'R N'p! p�,k,0.'v.'a:"RL w 1II,;:I' ,IalF,, 1HOIRI -HIco Uji I 'N','1111" CNNI[U or 1:111� J.r)rl>no n1unbuir. MIA1111 1: 0, 1: j� BUSTIFIR I:1 AILIDVVII:;11 j 2701 j ES GIARDF N (M�IROVIE, qZ'AP91840 (:n;'34 1111 1:1'N IZ)209 INSURED COPY 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 # (_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 provi ions or the agreement will automatically become void. Signature of Applicant .. Date May 16, 2019 Agreement for: ,...147M (". �. Dated: r I q Reviewed by: