— Sa RAT Acorn CERTIFICATE OF LIABILITY INSURANCE a... [ou nine’ CERT SRENT DOES Nee USD AS A HATTER OF NEORWATION ONLY anb CONFERS NO RGRTS UPON TIE SGOT oe os SEINIOATG 00S NOT AFRRATWELY OR NEGATIVELY Meno, CATEAD OR ATER Ta HovESuoy SE STE HOLDER THB Feet gis CERTFCATE OF INGURANGE pone Not GONGTTUTE A CONTRACT SeTscn Ve oui eee POLICES REPRESENTATVE OR PRODUGER AND INE GeSCNTT GS Tae RUAN, We ers Rli tan ADDITONAL WELRED, bm palo) male sade SUGROGRTON TS WANED SESS orcas at te a eal. aan poke may require an ehrdorerert. A satamet on bs eetoas toe ah oN eee [7 seiggueo Scour nA secs] s XXAXKEX | veo nunos [ESM femmes Ts oo { COOK amen HE TROT APPLICABLE Excrocsumnance |= GOGO xo | Treters £00000. cs NOT FCCRRCE Sue] SSeS [I wal elec} eer expanse cranial See SEATS 8 Brennan toe et bisgase “povoy uur Is XXXXKKK PESrITTON OF OPERATION LOCATIONS? VERLES (ASG hata Ramat Stns ave cid ame vous VSO ‘The Certificate Holder is included as Additional Insured where required by written and signed contractor permit subject to the terms and conditions ofthe General Liability policy, but only tothe extent bodily injury or property damage is caused in whole or in part by the acts or omissions of the insured, ‘CERTIFICATE HOLDER. (CANCELLATION Rancho Simi Recreation and Park Distt [SHOULD ANY OF THE ABOVE DesCrUDED POLICIES RE CANCELLCD BEFORE 1692 Syeamore Drive The xXAMATION DATE THEREOR, won WiLL SE ‘DELIGHGS ee Simi Vatey, Ca 93065, ACCORDANCE WITHTHE POLI PROVISIONS. RE: Festival Arts Youth Movement 3/12/2016, Rotary Club of Sen Sunrise t Jat kt ‘© FBit 2a ACORD CORPORATION. AllTghte ooerved. ACORD 25 (201401) ‘The ACORD name and logo are registered marks of ACORDPOLICY NUMBER: PMI 623867355007 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 Addi Rancho Simi Recreation & Park District 1692 Sycamore Drive ‘Simi Valley, CA 93065 RE: Rotary Club of Simi Sunrise (CA) Schedule on file with Lockton Companies. address. tal Insured Person(s) Or Organization(s): al Festival Arts Youth Movement, March 11-12, 2016 Where required by written contract provided that such was executed prior to the date of loss per This endorsement is only valid when additional insured information is completed including name and Information required to complete this Schedule, it not shown above, will be shown in the Declarations. ‘A. Section Il - 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 lave, 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, CG 20260413, © Insurance Services Office, Inc., 2012 B. With respect to the insurance afforded to these ‘additional insureds, the following is added to Section Ill - Limits Of Insurance: If coverage provided to the additional insured is Fequired by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 41. 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, Page 1 of 4Print Form U.S. Rotary Club & District Liability Insurance Program iz Certificate of Insurance Request Form «structions Complete and relum this form by email or fax along with a copy of the carliicalelinsurance requirements and contract (if applicable) from the organization requesting the certificate to: Lockton Companies Email: rotary@lockton.com Fax: (312) 681.4765 The certificate will be issued within 1-2 business days. Special requests may take longer to process. Questions? Call Lockton toll-free at (800) 921-3172 - Monday — Friday 8:30a - 4:30p (CT) Club or District Information Club Name & Number Rotary Club of Simi Sunrise District 5240 ‘Your Name Marshall Shrago Your Phone # | 605 )501_- 4443_| Your Email Address | tootimes @readunner-com YourFax# | (005) 522 57/57] Cerificate Holder (The entity requesting evidence of insurance) Entity Name Rasarto Sinn Recreation An Pek bisreier Malling Address | 7292 Syenmene be Sin; Volley, th $305 Contact Pe Fax # or Email emerson | ave tle ave. Adress Me MUKe Rak 3p, Date Needed Now dditional Insured Information 1s the certificate holder requesting additional insured status? ‘Yes No if yes, is this requirement stated in a written contract or permit with your club/district? If no, additional insured status cannot be provided. See Note below. if yes, please attach copy of that contract or permit. NOTE: Additional Insured status can ONLY be provided if required in a written contract or pemnitwith your Club/district. An Additional Insured is @ person or organization not automatically included as an Insured under an insurance policy, but for who limited insured status is granted. Additional Insured status does not extend full general lability insurance coverage to other entities, but rather provides limited coverage for an entity in the event a claim arises from your club or district's negligence. An Additional insured is not covered for iis own negligence. Description of the Event . Event Date(: Event Namo | Fe snvat- fers Your! Move nha ° eaeant 12,201 Event Location (City and State) [Simi Valley, California Description of the Event | syusic reetvel WITH: Entncernatenr InT@e RET; Ht Sexteol Sriorerns Distribution of the Certificate Send Xi Ceriificate Holder Eby e-mail (bami=le @_XsRPp. Us y certificate to: ptr x (number: . aa = ) ; . Insured Club/District ll by e-mail (lootimes- — @roadrunnen. 1 Bi by fax (number: SSSZA Ss )Rancho Simi Recreation and Park District "32" | 1622 syanere Or one 8055844400 ‘nsane | Simi Valley, CA 93065 Fax: / Account Schedule Report Phone: 805-501-4443 Email: toottime3@roadrunner.com Rotary Club of Rotary Club of Simi Sunrise Booking # RSRPD Rental Contract / Permit Rancho Simi Recreation and Park District, 1682 Sycamore Drive Simi Valley, CA 90365 hereby grants the “Permitiee”, permission to use the Facilities @s outined, subject t the Terms and Conditions ofthis Agreement contained herain and attached hereto all of which form part of this egreement, ‘The undersigned has read and on behalf ofthe Permittee agrees to be bound by this Permit and the Torms and Conditions contained herein ‘and attached hereto, and hereby warrants and represents that ha/she executes this Permit on behalf of the Permitae anu has eutfcient ‘power, authority and capacty to bind the Permittee with hiser signature. 4. Permittee must be in attendance at time specified and shail not leave facility unettended at any time. 2. certify that | have read end will abide by the rules and regulations of the Rancho Simi Recreation and Pak District, 3. User agrees to be solely responsibi for any and all ibily, claims, oss, damages, costs and expenses, Including atorney’s fees, rising ut of or resulting from any injury to persons or damage to property which arise out of is use of the District's facilities, User cgross to deter, Indemnity and hole harmless the District, its offcers, agents, employees and volunteers ageinst any and all such claims, demancs, causes of aciion, suits and expenses, erising out of or resulting from is use of the District's facies, 4, Permittee agrees to pay Rancho Simi Recreation and Park District for any cleaning anc damage fees incurred as a result of the Permittoo’s use ofthe faci, 5. The bearer of tis permits entited to exclusive use of stated rental araa atthe stated cay and times. All others shall vacate the area ugon presentation ofthis permit, 6. Permittes must remain in compliance with all conditions ofthis Permit, including any supplemental conditions attached hereto and incorporated herein, Any failure fo comply withthe conditions of this Perm shall authorize Rancho Simi Recreation ana Park District, in its dle discretion, to terminate Permittee's rights under this Permit and cancal the Permit in full. Such termination shall be Geemed 9 be "Tor '" and shall not give rise to any right on the part of Permittee fo seek relmbursement of amounts pald by Permittee in connection with Cbiaining or use ofthis Perm. in addition, Rancho Simi Recreation and Park District retains the ight to change in ts sole discretion any {oncition of this Permit, including any supplemental condition attached hereto and Inaorporated herein, of to cancel the Permit in is entirely. ‘Such change of cancellation shal be effective upon its communication to Permittee, which commurication shal be in wring. Should any {change or cancellation materially aftect Permites’s use and onjoyment of the Rancho Simi Recreation and Park Disticl property subject to {his Permit, Permittoe may seek a refund of some or all of the amounis paid by Permitie In connection with the use of (but Ret ebtaining of) {his Permit. Rancho Simi Recreation and Park Distt shall determine and grant a relund proportionate in value to the materiality of the Change in use or enjoyment ofthe property. 7. ttshall be Pormit Holder's responsibilty to determine whether or nota permit is required from the Ventura County Environmental Health Division (‘VCEHD)). This requires you to determine whether or not you are an "Event Organizer’ or "Food Vendor holding a "Commurity Event, within the meaning of those terms as defined by VCEHD. A permit can be required whether or not food or beverages are Sold or sivon away, prepared on or off-site, prepackaged, canned, botlad or served by the glass. Food infonded for public consumption ony not even be prepared st home, and it does not matter Ifthe intent ofthe event sto raise money for a club or other non-proft organization, Foilure to comply with these requirements may result in the closure of your event by VCEHD, among other things. 8. Permissions to use the Park District property described inthis permit is given solely to the permitize. The Permittee may not assign its Tights under this permit to any other entity 0 or individual, and it may not permit others to occupy or use the property without prior written approval ofthe Park District 8. Rancho Simi Recreation and Park District's Cancellation Policy (12-900-B) for Facility Use is as follows: More than 45 days prior to the event, 25% of the area reservation fee retained. 30-44 days prior to the avant, 50% of the area reservation fee retalned. Less than 20 days bor to the even, 75% ofthe area reservation fee retained. A fll refund shall be given when the Disiiet cancels the use ofthe facilty or ‘when inclement weather prohibite'use gf the outdoor fecities are reserved. "Printed on 37172076 2:29:00 PM Page 2A=. Rancho Simi Recreation and Park District 1692 Sycamore Dr Phone: 805-584-4400 imi Valley, CA 93065 Fax: Account Schedule Report Phone: 805-501-4443 Rotary Club of Simi Sunrise Email: tooltime3@roadrunner.com Harsarsrrage (NAL Fase A PO Box 940326 ‘Simi Valley, CA 93094 ‘Account Schedule «By Date 3ni1i2016 - 3/1212016 SMIROG Fr RSCP SCPC Boul Event ‘000000 000 aan smote pn RSP RSG Event 1m 0m 00 000 = oan samme set RSP ASCP vent wo om 099 00000 ‘Ampnthesier sranore set_RSCP 8:00 Aut0-00 Pat 140 000 09 000 _ ao 30 (ray OGD ‘Sub Total $0.00 Tax $0.00 Grand Total ‘$0.00 free z Paget nied on SHI2076 2:29:00 PMRANCHO SIMI RECREATION AND PARK DISTRICT 1092 Sycamore Drive, Sin Vat, Calorie 83065 + (205) 84.4400 « FAX (805) 526-7025 Web Page: wasp. PERMITTEE INSURANCE REQUIREMENTS FOR USE OF DISTRICT FACILITIES | Acceptable Evidence of Appropriate Insurance Coverages: A. Permittee shall submit to the District a Certificate of Liability Insurance naming the District as the Certificate Holder. 8. An Additional Insured Endorsement is required with the District's name and address on it. Nl Minimum Coverages: A. General Liability ~ Occurrence Basis Required and Additional insured 8. Host Liquor Liability (if alcoholic beverages will be served at the event at no charge), or Liquor Legal Liability (if alcoholic beverages will be sold at the event). ML _Minimum Limits: The Minimum coverage limits shall be in the principle amount oF $4,000,000. Combined Single Limits as to bodily injury to persons and damage to property, with a $2,000,000 aggregate. NOTE: A Certificate of Insurance must be received by the District prior to the District’s approval of the Use of Facilities Permit. CERTIFICATE HOLDER AND ADDITIONAL INSURED ENDORSEMENT TO: Rancho Simi Recreation and Park District 1692 Sycamore Drive Simi Valley, CA 93065 CATERERS MUST ALSO HAVE A CERTIFICATE ON FILE WITH THE PARK DIST.