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CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 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 CONTACT NAME: PHONE (A/C, No, Ext): FAX (A/C, No, Ext): E-MAIL ADDRESS: NAIC # INSURER(S) AFFORDING COVERAGE INSURED INSURER A: INSURER B: INSURER C: INSURER D: INSURER E: INSURER F: COVERAGES REVISION 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 LTR TYPE OF INSURANCE ADDL INSR SUBR WVD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN’L AGGREGATE LIMIT APPLIES PER: POLICY PRO- JECT LOC EACH OCCURRENCE DAMAGE TO RENTED PREMISES (Ea occurrence) MED EXP (Any one person) PERSONAL & ADV INJURY GENERAL AGGREGATE PRODUCTS - COMP/OP AGG $ $ $ $ $ $ $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS HIRED AUTOS SCHEDULED AUTOS NON-OWNED AUTOS COMBINED SINGLE LIMIT (Ea accident) BODILY INJURY (Per person) BODILY INJURY (Per accident) PROPERTY DAMAGE (Per accident) $ $ $ $ $ UMBRELLA LIAB OCCUR EXCESS LIAB CLAIMS-MADE DED RETENTION $ EACH OCCURRENCE AGGREGATE $ $ $ WORKER’S COMPENSATION AND EMPLOYERS’ LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? If yes, describe under DESCRIPTION OF OPERATIONS below WC STATU- TORY LIMITS OTH- ER E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE E.L. DISEASE - POLICY LIMIT $ $ $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / (Attach ACORD 101, Additional Remarks Schedule, if more space is required) THIS CERTIFICATE SUPERCEDES ALL PREVIOUSLY ISSUED CERTIFICATES FOR THIS HOLDER, APPLICABLE TO CARRIERS LISTED AND THE POLICY TERM(S) REFERENCED. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE OTHER CERTIFICATE NUMBER: Insurance Agent Name/Address Insured’s Name/Address A X Y Y Y Y N/A Y Y Y Policy Number 2,000,000 1,000,000 5,000,000 2,000,000 5,000 2,000,000 1,000,000 1,000,000 1,000,000 The City of Palmdale, Housing Authority, Palmdale Finance Authority, Successor Agency to the Community Redevelopment Agency of the City of Palmdale, Industrial Development Authority, Airport Authority, and their officers, agents, employees and volunteers are named as additional insured. Include name and date(s) of event(s). City of Palmdale Department of Parks & Recreation 827 East Avenue Q-9 Palmdale, CA 93550 Authorized Representative’s Signature X X X X X A A Insurance Company Name ACORD 25 (2010/05) ©1998-2010 ACORD CORPORATION. All rights reserved. Policy Term (must cover event dates) $ $ $ 2,000,000 2,000,000 5,000,000 PER OCCURRENCE GENERAL AGGREGATE PER OCCURRENCE OR CLAIMS-MADE BASIS Liquor Liability Sexual Abuse & Molestation A B Certificate of Liability Insurance Requirements MEDIUM HAZARD USE As required by your contract terms, a Certificate of Liability Insurance with Additional Insured Endorsement must be provided to us directly by your insurance agent. All sections must be completed as shown in the example below. DISCLAIMER: PLEASE REFER TO THE AGREEMENT BETWEEN THE CITY OF PALMDALE AND THE CONTRACT HOLDER FOR SPECIFIC INSURANCE REQUIREMENTS. IT IS RECOMMENDED THAT THE CONTRACT HOLDER PROVIDE A COPY OF THE INSURANCE REQUIREMENTS IN THE CONTRACT TO THE INSURANCE COMPANY FOR REVIEW AND COMPLIANCE. Please submit your Certificate of Liability Insurance with the following requirements: 1. Issue date is required. 2. Insured name must be identical to the Legal Entity Name listed on the contract. 3. Insurance company(ies) must be authorized to do business in the State of California. 4. REQUIRED GENERAL LIABILITY: $2,000,000 Per Occurence limit $5,000,000 General Aggregate limit If food, drink or any kind of product is sold or given away at the event: $2,000,000 Products & Completed Operations Aggregate limit Additional Insured Endorsement required. 5. Policy number. 6. Policy term must cover date(s) of event(s), including set-up and teardown. 7. REQUIRED MEDICAL EXPENSES AND PERSONAL & ADVERTISING INJURY: $5,000 Med Exp (Any One Person) $2,000,000 Personal & Adv Injury 8. REQUIRED AUTOMOBILE LIABILITY: $1,000,000 Combined Single Limit including owned, non-owned and hired automobile coverage. Additional Insured Endorsement required. REQUIRED WORKER’S COMP: California Statutory Requirements. EMPLOYER’S LIABILITY: $1,000,000 Each Accident $1,000,000 Disease - Each Employee $1,000,000 Disease - Policy Limit 10. If alcohol is served or sold, REQUIRED LIQUOR LIABILITY: $2,000,000 Per Occurrence $5,000,000 General Aggregate If event holder’s membership consists of children, REQUIRED SEXUAL ABUSE & MOLESTATION LIABILITY: $2,000,000 per occurrence or on a claims-made basis 11. REQUIRED WORDING: The City of Palmdale, Housing Authority, Palmdale Finance Authority, Successor Agency to the Community Redevelopment Agency of the City of Palmdale, Industrial Development Authority, Airport Authority, and their officers, agents, employees and volunteers are named as additional insured. Include name and date(s) of event(s). 12. City of Palmdale Dept. of Parks & Recreation 827 East Avenue Q-9 Palmdale, CA 93550 13. Authorized representative’s signature required. See next page for required Additional Insured Endorsement sample. Submit Certificate of Liability Insurance & Additional Insured Endorsement to: City of Palmdale Department of Parks & Recreation 827 East Avenue Q-9, Palmdale, CA 93550 661/267-5611 • Fax 661/267-5636 SAMPLE SEND TO YOUR INSURANCE COMPANY ---PAGE BREAK--- Note: Your insurance carrier must be located in and licensed to do business in the U.S.A POLICY NUMBER: COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED – DESIGNATED PERSON OR ORGANIZATION SCHEDULE This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART COMMERCIAL AUTO LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART SEXUAL ABUSE & MOLESTATION PART Name of Additional Insured Person(s) or Organization(s): The City of Palmdale, Housing Authority, Palmdale Finance Authority, and their officers, agents, employees and volunteers are named as additional insured. Additional Insured Endorsement Requirements You must submit your Additional Insured Endorsement with your Certificate of Liability Insurance. All sections must be completed as shown in the example below. Please submit your Additional Insured Endorsement with the following requirements: 1. Policy Number(s) for Commercial Liability and Commercial Automobile Liability (mandatory). If serving or selling alcohol, include policy number for Liquor Liability (mandatory) 2. Commercial Liability and Commercial Automobile Liability. If serving or selling alcohol, Liquor Liability. 3. The City of Palmdale, Housing Authority, Palmdale Finance Authority, their officers, agents, employees and volunteers are named as additional insureds. NOTE: Your insurance carrier must be located in and licensed to business in the State of California.