PROOF OF INSURANCE (2019 - 2020) CLOSED''
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CERTIFICATE
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LIABILITY
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`! Box 1250
Midlothian,
Certificate Holder is An Additional Insured, But Only As Respects The Operations Of The Named Insured
CIS R I II...IC,A I I.:: p...tlu":UII...DER CAIeUCE..I. N...ATIION
aA-NdD0.YN..II.D ANY C'.91F IIIIE AIROW1U DE'SCRI&E.C'7 G'ri 1-K.lE,•S BF CANCICILII.IF':D I?Y.ml"i 1G M1."
TTNIE EXIMISAil"PIDNq n,N"N'IF.. TIHEIM-Oli IT0rNCF W(VPRCV BEIIDN d.NWFERIE Y IN
City of El Segundo akCCC0Rr.:)AN F0uru IIYUFPOLICY PROWrI K)Il l
350 Main St.
EI Segundo, CA 90245 ,IH1WK11"11 V 11114 111 7 w NIIII'111111"I''
John W 'Frazier
011988..-2010 ,A"COU'ro"GD GC-1IRPial(wATIIC.,N All ri¢',pk, s uo:*'sien,ved
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v\\d r v, xrsaJ F l w Rl�,k Cwui Inc
Twlistled Tales I....Iaunted House
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El Segundo, CA 9024
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CERFIV.:.PC,ATE
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Policy F LSP -200-19 08/1212019
111012019 1
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Ce FCA -E-0090
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Certificate Holder is An Additional Insured, But Only As Respects The Operations Of The Named Insured
CIS R I II...IC,A I I.:: p...tlu":UII...DER CAIeUCE..I. N...ATIION
aA-NdD0.YN..II.D ANY C'.91F IIIIE AIROW1U DE'SCRI&E.C'7 G'ri 1-K.lE,•S BF CANCICILII.IF':D I?Y.ml"i 1G M1."
TTNIE EXIMISAil"PIDNq n,N"N'IF.. TIHEIM-Oli IT0rNCF W(VPRCV BEIIDN d.NWFERIE Y IN
City of El Segundo akCCC0Rr.:)AN F0uru IIYUFPOLICY PROWrI K)Il l
350 Main St.
EI Segundo, CA 90245 ,IH1WK11"11 V 11114 111 7 w NIIII'111111"I''
John W 'Frazier
011988..-2010 ,A"COU'ro"GD GC-1IRPial(wATIIC.,N All ri¢',pk, s uo:*'sien,ved
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COMMERCIAL CIAL GENERA) LIABILITY
ITY
(.C; 20 26 (14 13
ORGANIZATIONADDITIONAL INSURED - DESIGNATED PERSON OR
insnared� 'Twisted Tales Haunted House
Poky Number: F L P...200...jg
This endorsement modifies insurance provided under the fca lowing:
C01Mlrw ERCIIAsIL GENE: IL t.IABILITY COVERAGE IPAmIRT
SCHEDULE
Name Of Additional Insured Person(s) Or Organization(s):
a.,lry offl::.� ;'�roeguu"ua:to
350
F] Segiuridin C/1 90245
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6rnfarrrnatuar•n ruMr�nrprvar9 to �o� al�ar„�, tl•nus Schedule, if.not sVnown above wupll tn�� ��snraw^��rr us• ..
A. Section III m WHO IS AN INSURED is amended to
include as an insured the person(s) or organszat on(s)
shown in the Schedue, but only with respect to RatuiPity
for"k.ar wily, nraynrry' ' Property udannatta' or up°,rr:r,caa"nab mid
adve;.tw,„,wsrrg canary catised in voroie or in raao c.)y yrausr
act',, or rm,,issiowr of me ac!*, or' ,r rra.rrsskrr s , 4 ts. r)se
acting on your it half:
A. in the performance at your ongoing operations; or
B. in connectlan with your premises owned by or
rented to you.
CG 20 26 07 i'::; f rr.:rolfu, ld.rs,, Jrmr,.;::sa,:i Page i of 1
COMMERCIAL GENERAL LIABILITY
CG 24 04 05 09
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY
AGAINST OTHERS TO US
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Policy Number. FGLSP-200-19
Insured: Twisted Tales Haunted House
COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY
COVERAGE PART
SCHEDULE
Name Of Person Or Organisation:
City of EI Segundo
350 Main St.
EI Segundo, CA 90245
Information required to complete this Schedule, Declarations.
�w q p edule, if not shown above, will be shown m the De tions.
The following is added to Paragraph S. Transfer Of
Rights Of Recovery Against Others To Us of
Section IV - Conditions:
We waive any right of recovery we may have against
the person or organization shown in the
Schedule above because of payments we make for
injury or damage arising out of your ongoing
operations or "your work" done under a contract
with that person or organization and included in
the "productscompleted Operations hazard. This
waiver applies only to the person or organization
shown in the Schedule above.
06282019
Here is your Automobk �n surance Poky EXPECT
Renewal Declaration Certificate pr SOMETHING
MORE'"
Vehicle Information
Vehicle: 2018 BMW X24DR 4WD
. . . . . . . . . . . . . .
Vehicle: 2017 MAZDA CX -5 4DR 4WD
. . . . . . . . . . . . . . . .
Vehicle Identification Number
.. .
WBXVJ5C331EF71107
JM3KFBDL7HO192298
Vehicle Rated Address
155 Bluegrass Dr Hendersonville, TN 37075-2751
155 Bluegrass Dr Hendersonville, TN 37075-2751
Assigned Driver
MICHELLE JAURE
Joshua Mankini
Titleholder
MICHELLE JAURE
Joshua Mankini
Lienholder
NIA
NIA
Vehicle Usage
Drive To Work/School use, less than 10,000 miles
Pleasure use, less than 10,000 miles per year
Vehicle lease/ Purchase Date
$24.11
Dec 23 2017
Additional Discounts
Vehicle Safety, Anti -Theft Device
Vehicle Safety, Anti -Theft Device
Coverage
Vehicle: 2018 BMW X2 4DR 4WD
Vehicle: 2017 MAZDA CX -5 4DR 4WD
Coverage Offered
Limits of Liability
Premium
Limits of Liability
Premium
Bodily Injury Liability
$500,000 each person/
$5372
$500,000 each person/
$46.96
$500,000 each accident
$500,000 each accident
Property Damage Liability
$500,000 each accident
$28.65
$500,000 each accident
$24.11
Medical Payments
$10,000 each person
$12.79
$10,000 each person
$11.19
Uninsured/ Underinsured Motorists
$500,000 each person /
$43,88
$500,000 each person /
$43.88
Bodily Injury
$500,000 each accident
$500,000 each accident
Uninsured Motorists Property Damage
$500,000 - $200 Deductible
$17.20
$500,000 - $200 Deductible
$17.20
Comprehensive
$500 Deductible w/Full Glass
$64.37
$500 Deductible w/Full Glass
$39.65
Collision
$500 Deductible
$151.18
$500 Deductible
$77.17
Enhanced Exterior Repair Option
Included
Included
Car Rental
$40 per day/$1,200 maximum
$15.36
$40 per day/$1,200 maximum
$15.36
Loan/Lease Gap
Not Included
Not Included
Extra Equipment
Not Included
Not Included
Enhanced Total Loss Replacement
$15.09
$8.18
Transportation Network Company
Not Included
Not Included
Total Premium Per Vehicle
$402.24
$283.70
Policy Level Coverage
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Broadened Other Car Not Included
Total Premium $1,313.30
8600 22317-TN2 1018
Member5elect Insurance Company Your agent is
Policy Number AUT700033581 ACG South Insurance 855-647-3846 0
ACGSOUTHINSURANCE@AAASOUTH 5 of 5
Policy Term Aug 15 2019 to Feb 15 2020 Agency, LLC .COM
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 forthe 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 #
(_!G) 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 provisionsor the agreement will automatically become void. 8/14/19
Signature of Applicant Date
Print Name
Ryan Jaure `
w...
Agreement for:
Dated: F
Reviewed by:
......
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