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PROOF OF INSURANCE (2020 - 2020) CLOSEDCERTIFICATE OF LIABILITY INSURANCE 9/16/2019 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 Contact Name: Larry Cossio Cossiolnsurance Agency Phone (864)688-0121 Fax PO Box 5987 AIC, No Ext): A/C, No): Greenville, SC 29606 E -Mail: shay@cossioinsurance com (864) 688-0121 INSURER(S) AFFORDING COVERAGE NAI C# I INSURER A: Nationwide Mutual Insurance Company 23787 INSURED Jump For Joy INSURER B: Berkley Life & Health Insurance Company 64890 530 South Francisca Avenue Redondo Beach, CA 90277 INSURER C: INSURER D: INSURER E: 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 INSR TYPE OF POLICY ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR WVD (MM/DD/YY) (MM/DD/YY) X COMMERCIAL GENERAL LIABILITY General Agg (Other than Products -Co $2,000,000 ❑ ❑ CLAIMS MADE 7 OCCUR Each Occurrence $1,000,000 Products and Completed Operations $1,000,000 ❑ Personal and Advertising Injury $1,000,000 A ❑ X FWC0000030941600 9/20/2019 9/20/2020 Legal Liability to Participants $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER Professional Liability (for Event Plann $1,000,000 X POLICY ❑ PROJECT ❑ LOC Damages to Premises Rented to You $300,000 Participant Accident - Excess Medical $10,000 ❑ OTHER: Deductible $0 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ F-]ANYAUTO (Ea accident) ALL OWNED SCHEDULED ❑ L.. Person) BODILY INJURY..(.P.er.. $ AUTOS AUTOS ........................................... ❑ HIRED AUTOS I������������° NON -OWNED BODILY INJURY Per accident ( ) $ ';.,...I AUTOS ,................ ❑ PROPERTY DAMAGE $ (Per accident) ❑ UMBRELLA LIAB ❑ OCCUR ❑ EXCESS LWB ❑ CLAIMS -MADE ❑ DED ❑ RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN OFFICER/MEMBER EXCLUDED?71N/A (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below PEROTH- STATUTE ER Accident Medical Deductible $100 Benefit Period 52 weeks B Accident Medical PAI L012010630902 9/20/2019 9/20/2020 Benefit Maximum $500,000 Applies During per Covered Accident Applies To ' Death & Dismemberment Benefits only DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (AC3RD 101, Additional Remarks Schedule, may bett attached if more spat s required) ... e iir . . ed) Party Equipment Rentals Operations located at 530 South Francisca Avenue Redondo Beach, CA 90277, Certificate Holder is listed as additional insured perform CG2011, The certificate holder is added as an additional insured, but only for liability caused, in whole or in part, by the acts or omissions of the named insured Amusement devices on file with the company for special event(s) dated 9/20/2019 to 9/19/2020 located at 350 Main Street, EI Segundo, CA 90245. CERTIFICATE HOLDER: CANCELLATION City Of EI Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 350 Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN EI Segundo, CA 90245CORODANCE WITH THE POLICY PROVISIONS. UTH' A ............... ......... �...�. _ .........,,,,,.. A RIZED REPRESENTATIVE , @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: FWC0000030941600 COMMERCIAL GENERAL LIABILITY CG 20 11 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL (INSURED - MANAGERS OR LESSORS OF'PREMISES This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Designation Of Premises (Part Leased To You): Name Of Person(s) Or Organization(s) (Additional Insured): City Of EI Segundo 350 Main Street EI Segundo, CA 90245 Additional Premium 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 arising out of the ownership, maintenance or use of that part of the premises leased to you and shown in the Schedule and subject to the following additional exclusions: This insurance does not apply to 1. Any 'occurrence" which takes place after you cease to be a tenant in that premises. 2. Structural alterations, new construction or demolition operations performed by or on behalf of the person(s) or organization(s) shown in the Schedule. 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 11 0413 ©insurance Services Office, Inc., 2012 Page 1 of 1 1. Named Insured RON &VALERIE IACOPUCCI 530 S FRANCISCA AVE APT#B REDONDO BEACH, CA 90277-4241 Your Insurer TRAVELERS COMMERCIAL INSURANCE COMPANY ONE TOWER SQUARE, HARTFORD, CT 06183 Your Auto Policy Number 996024601 203 1 Your Account Number 941113867 Your Service Center Address TRAVELERS C/O KNOXVILLE BUSINESS CENTER P.O. BOX 59059 KNOXVILLE, TN 37950-9059 For Policy Service 1.800.842.5075 For Claim Service For questions on filing a claim or to file a claim go to Travelers.com or call 1.800.252-4633 2. Premium Your Total Premium for the Policy Period is $1,576. The policy period is from August 1, 2019 to February 1, 2020 12:01 A.M. STANDARD TIME at your address shown in Item 1. 3. Your Vehicles Identification Numbers 1. 2006 TOYOT TUNDRA LIM 5TBDT48126S519837 2. 1990 FORD F350 2FDKF37M1 LCA88678 3. 2001 TOYOT AVALON XIJ 4T1 BF28131 1 U131498 A 9010 TOYOT PRIUS JTDKN3DUXA01 48831 O 4. Coverages, Limits of Liability and Premiums Insurance is provided only where a premium entry is shown for the coverage. The premium entry "Incl" or "Pkg" means the premium charge is included in the premium for another coverage or a package. VEHICLE 1 VEHICLE 2 VEHICLE 3 VEHICLE 4 PL -50014 (03-12) Page 1 of 4 6701OM1605 06 TOYOT 90 FORD 01 TOYOT 10 TOYOT TUNDRA LIM F350 AVALON XL1 PRIUS A. Bodily Injury each person 1$1100,000 $300,000 each accident $224 $250 $167 $173 B. Property Damage $50,000 each accident $106 $88 $63 $67 D1. Uninsured Motorists Bodily Injury $100,000 each person $300,000 each accident $49 $65 $49 $49 E. Collision Actual Cash Value less $2,500 deductible $71 $34 $72 PL -50014 (03-12) Page 1 of 4 6701OM1605 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 I Policy Number Expiration Date Phone # CX 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 pr71=2 s or the agreement will automatically become void. Signature of Applicant �...1 - '� Date Print Name Agreement for: 3QMP,2K (-�— 1p P 4 �53 Dated: ..._ Reviewed by: � .�- ......�.