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PROOF OF INSURANCE (2019 - 2019) CLOSED" 0 DATE(MWDD/YYYY) ,�(+�'CW" CERTIFICATE OF LIABILITY INSURANCE' �I 06/27/2019 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 SONIALf PHONE FAX HCC Specialty _....._...Mq• esu: I...s: ARA 401 Edgewater Place, Suite 400 ADDRESS: Wakefield, MA 01880 tp.N)r� up ONSURER{) AFFORDING covE _.................... RAGE NAIC $ INSURED IN ............... New Hampshire Insurance Company 23841 SURER A : C ..........._.. .... Shawn Blakely INSURERS: United States Fire Insurance Company 21113 5513 Rockne Ave. INSURER.c.:..............�............. Whittier, CA 90601 INSURER D : INSURER E : INSURERF: COVERAGES CERTIFICATE NUMBER; REVISION NUMBER: THIS IS O CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERtlOD (INDICATED, NOTWITHSTANDING ANY REQUIREMENT, T'E'RM OR CONDITION( OF ANY CONTRACT' OR OTHER DOCUMENT WITH RESPECT' TO WHICH THIS CERTIFICATE MAYBE, ISSUED OR MAY PERTAIN., "THE INSURANCE AFFORDED BYTHE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL'1"HE TERM'S, EXCLUSIONS AND CONDITION'S' OF SUCH POLICIES. LIMITS SHOWN MA'Y HAV'E'BEEN REDUCED BY PAID CLAIMS. INSii°......................._................ ..SR..SWYiJ LICYNUMBER...............II LIMn'5.......... TYP� PO MIWDD YYYY)..L.dP4�7�k�.NDV-'���'Km4d.""." LTR EOFINSURANCE � { MI4pJODRYYYYI GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X OCCUR X Host Liquor B .X Medical Expense .............. . GEN'L AGGREGATE LIMIT APPLIES PER: I PRO; X POLICY LOC AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS UMBRELLA LIAB _ OCCUR EXCESS LIAB CLAIMS -MADE, DEDUCTIBLE RETENTION Y WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED' (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below X SEL065470363 07/02/2019 07/07/2019 OCCURRENCE... '� $ $ PPIF ENY 0' .t'°°........ _ME,Q5XP.(Any..one, isop)....__.. _$ PERSONAL 8 ADV ..................V INJURY $ US1109007 07/02/2019 07/07/2019 GENERAL AGGREGATE $ PRODUCTS..-..COMP/OP AGG _ .......................... $ E.L. DISEASE- POLICY LIMIT $ COMBINED SINGLE LIMIT $ (Ea accident) ............ .........._.--_-...-- URY BODILY INJ..(Per person) $ .................. ......... BODILY INJURY (Per accident) $ OP D E DAMAGE (Per $ i accident) _.... ........................... EACH OCCURRENCE ,AGGREGATE $ T�IAY_i.IMITS I vF �.... E.L. EACH ACCIDENT $ E E. L, DISEASE..:.....A EMPLOYEE $........ E.L. DISEASE- POLICY LIMIT $ 1,000,000 300,000 5, 00.0 1,000,000 2,000,000 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, it 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 EI Segundo 4th of July event to be held 07/04/2019 - 07/04/2019 at Recreation Perk EI Segundo CA CERTIFICATE HOLDER CANCELLATION CityofElSegundo, itsofficers, officials, employees,agents, and volunteers ESCRIBED POLICIES BE CANCELLED BEFFORE THE EXPIRATION DAHOULD ANY OF THE ABOVE TE THEREOF, NOTICE WILL BE DELIVERED 3500 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: 65470363 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): CityofElSegundo,itsofficers,officials,employees,agents,and volunteers 3500 Main Street 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 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. 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 26 04 13 0 Insurance Services Office, Inc., 2012 Page 1 of 1 INSURANCE IDENTIFICATION CARD INSURANCE IDENTIFICATION CARD STATE: CALIFORNIA STATE: CALIFORNIA COMPANY: 21st Century Insurance Company COMPANY: 21st Century Insurance Company POLICY NO: 2036-97-13 COMPANY NO: 12963 POLICY NO: 2036-97-13 COMPANY NO: 12963 EFFECTIVE DATE: EXPIRATION DATE: EFFECTIVE DATE: EXPIRATION DATE: 02/17/2019 08/17/2019 02/17/2019 08/17/2019 VEHICLE IDENTIFICATION NUMBER: YEAR: VEHICLE IDENTIFICATION NUMBER: YEAR: 5NPEB4AC2DH731148 13 5NPEB4AC2DH731148 13 MAKE/MODEL: HYUN SONATA GLS SD MAKE/MODEL: HYUN SONATA GLS SD INSURED: INSURED: SHAWN BLAKELY SHAWN BLAKELY VERONICA PARRA VERONICA PARRA 5513 ROCKNE AVE 5513 ROCKNE AVE WHITTIER, CA 90601-2134 WHITTIER, CA 90601-2134 I AGENCY/COMPANY ISSUING CARD: AGENCY/COMPANY ISSUING CARD: 21st CENTURY INSURANCE 21st CENTURY INSURANCE 21ST CENTURY PLAZA 21ST CENTURY PLAZA P.O. BOX 15510 P.O. BOX 15510 WILMINGTON, DE 19850.5510 WILMINGTON, DE 19850-5510 THIS POLICY MEETS MINIMUM COVERAGES REQUIRED BY LAW THIS POLICY MEETS MINIMUM COVERAGES REQUIRED BY LAW IN SECTION 16056. IN SECTION 16056. SEE IMPORTANT NOTICE ON REVERSE SIDE SEE IMPORTANT NOTICE ON REVERSE SIDE SEE REVERSE FOR EXCLUDED DRIVERS SEE REVERSE FOR EXCLUDED DRIVERS ID - CA (5/18) ID - CA (5/18) Please note you are required by law to keep this card with you when in your vehicle. You may need it to renew your license and/or vehicle registration and you will need to provide it as proof of insurance if requested by a law enforcement officer. Please check the name, address and vehicle information on the ID card to make sure it matches your registration. If any of the information is incorrect, please contact us to correct it. Please check the following without delay: 0 Check the surname and vehicle description on your Insurance ID Card to make sure the card matches your Automobile Registration. a Check the VIN on your ID Card to make sure that it matches your Registration. 0 If any of these items are incorrect, do not alter your ID Card. Please call the Policy Service number listed on the back of your ID Card. A revised ID Card will be sent whenever you make any name, address or vehicle changes. We will send you a replacement ID Card prior to your next renewal term. THIS CARD MUST BE KEPT IN THE INSURED VEHICLE AND PRESENTED UPON DEMAND HELPPOINT® CLAIM SERVICES In case of accident or loss, call any time to report a claim: 1-(888)-244-6163 Obtain the following information: 1. Name and address of each driver,passenger and witness. 2. Name of Insurance Company and policy number for each vehicle. POLICY S'ER'V'IC'E 21st ROADSIDE To make a change to your ASSISTANCE policy call: For help, call: 1-(800)-241-1188 1-(800)-439-5587 EXCLUDED DRIVERS: ELIDA PARRA THIS CARD MUST BE KEPT IN THE INSURED VEHICLE AND PRESENTED UPON DEMAND HELPPOINT® CLAIM SERVICES In case of accident or loss, call any time to report a claim: 1-(888)-244-6163 Obtain the following information: 1. Name and address of each driver,passenger and witness. 2. Name of Insurance Company and policy number for each vehicle. POLICY SERVICE 21st ROADSIDE To make a change to your A'SS'ISTA'NC'E policy call: For help, call: 1-(800)-241-1188 1-(800)-439-5587 EXCLUDED DRIVERS: ELIDA PARKA 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. (_) 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 # Lam) 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 becom., subject to the workers' compensation provisions of Labor Code § 3700 1 must immediately comply tiooo����Jr the agreement will automatically y ecome void. Signature of Applicant 7 Date - Print Name' • p'' ",i" -I P h .. . . ....... ..� Agreement for: Dated: Reviewed by: