PROOF OF INSURANCE (2020) CLOSEDACCR I DATE IYYYY)
., CERTIFICATE OF LIABILITY INSURANCE VOSl20/2019019
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(les) 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 si.
CON'TT'
PRODUCER .. ... .. NAME: Ali,-SUllta .........
Arthur J. Gallagher Risk Management Services, Inc. PHONE F. 1-8-3ROTARY I FAX 630-285-4062
2850 Golf Road �.- _..... _._._.I° .._._....._.— —
E-MAIL rotary@ajg.corTl„__
Rolling Meadows IL 60008
VINSURERISIAFFORDING COVERAGE _— - _ - _
ry C........._ _._............
INSURER A: Lexinqton Insurance Company 19437
INSURED . INSURER B
All Active CJS Rotary Clubs & Districts INSURER O:
Rota
Club of EI Segundo
ATTN: Risk Management Dept. INSURER D:
1560 Sherman Ave. ' INSURERE:
Evanston, IL 60201-3696 INSURER F:
COVERA„GES CERTIFICATE 1IU,MBER. 899307648 REVISION „kUMBE'R.
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN 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
CERT'IFICAT'E 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..
-- - - ADD'Cf9�Y70A............... POLICY EI° POLICY E'XP T
IL7A 1YPEOFINSURANCE IVSD wIVD POLICYNUMBER 'm W�dDo ,I,,,,�NUAAID&]i"1 , LIMITS
A v COMMERCIAL GENERAL LIABILITY 015375594 711/2019 7/1/2020 EACH OCCURRENCE 52,000,000
CLAIMS -MADE 5� OCCUR
_l iuor Liabilit/( Irgdude,
GEN'L AGGREGATE LIMIT APPLIES PER
POLICY ❑ JECT
PRO- 17 LOC
OTHER:
A AUTOMOBILE LIABILITY
ANY AUTO
OWNED
AUTOS ONLY
HIRED
x AUTOS ONLY
UMBRELLA LIAR
SCHEDULED
' 49SCHEDULEDLyED
x 2TO
�_l OCCUR
EXCErySSLIAB _ CLAIMS -MADE
DED I I RETENTIONS
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y I N
ANY PROPRIETOR/PARTNER/EXECUTIVE❑ N I A
OFFICER/MEMBER EXCLUDED?
(Mandatory In NH)
if yes- describe under
DESCRIPTION OF OPERATIONS below
DAMAGE TO RENTED
_efKF.MSESIEsorcuuerKO
$500,000
MED EXP (Any one person)
...............
$
_............
PERSONAL & ADV INJURY
52.000,000
GENERAL AGGREGATE
$4,000,000
PRODUCTS-COMP/OPAGG
$4.000,1300
S
015375594 Eamm
7!112019 7!112020 COMIIIMEOSS'INd3LELIMIT
arc+dreull
$2,000,000
$
..
BODILY INJURY (Per person)
$ _
BODILY INJURY (Per accident)
S
-
$
m r accldoml
NOT APPLICABLE EACH OCCURRENCE wm,
$
AGGREGATE
$
NOTAPPLICABLE STATH
I ER_
TUTE N ,..._
E.L. EACH ACCIDENT
$
E.L. DISEASE - EA EMPLOYE)
$ .----�......
E.L. DISEASE -POLICY LMrf.E
DESCRIPTION OF OPERATIONS l LOCATIONS f VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached It more space Is required)
The Certificate holder is included as additional insured where required by written contract or permit subject to the terms and conditions of the
general liability policy, but only to the extent bodily injury or property damage is caused in whole or in part by the acts or omissions of the
insured.
_V`2v
CERTIFICATE HOLDER CANCELLATION
City of EI Segundo, Its officials, and Its employees SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
350 Main Street, EI Segundo, California 90245 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS,
Re: Twisted Tales Event --October 3 -October 31, 2019
Event Site: EI Segundo Teen Center -405 E. Grand Avenue, AUTHORIZED REPRESENTATIVE
El Segundo, California 90245
9)1988-2016 ACORD CORPORATION. All rights reserved.
ACORD 26 (2016103) The ACORD name and logo are registered marks of ACORD
ENDORSEMENT No.019
This endorsement, effective 12:01 AM 07101/2019
Forms a part of policy no.: 015375594
Issued to: US ROTARY CLUBS & DISTRICTS
C/O ROTARY INTERNATIONAL
By: LEXINGTON INSURANCE COMPANY
ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION
(Based on CG2026 04/13)
This endorsement modifies insurance provided by the following:
COMMERCIAL GENERAL LIABILITY POLICY
SCHEDULE
Name of Additional Insured Person(s) or Organization(s)
City of A Segundo
350 Main Street, El Segundo, CA 90245
Event: Rotary El Segundo Club Haunted House
Event Dates: October 3-31, 2019
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
organizations) 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
All other terms and conditions of the policy remain the same.
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 El 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 #
(Z I certify that, in the performance of the work set forth in the agreement with the City of EI Segundo, 1 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 ovisions or the -agreement ill automatically become void.
Signature of Applicant ~"� Date
Print Name
Agreement for: / .
Ado
� 'e,72,
M
Dated: -,, )
Reviewed by: