HomeMy Public PortalAboutC-23-208 - LA LA - 2023 WHITE LINEN SPAVendlor iD: Sor
mus
City of Carson
Community Services Department Mie
Service Provider Application Better:
Dear Applicant,
On behalf of the City of Carson, I would like to thank you for taking the time to explore business
opportunities with the City by applying to provide services for an event at a City facility. As part
of our application process, you must complete, sign, and return the following forms. Submission
of these forms does not guarantee that you will be provided the business opportunity you seek.
Your prompt assistance in submitting the requested documentation to the City staff member
listed below will be appreciated and will help expedite the application process. Please send your
completed application and attachments directly to the following address:
City of Carson
Attn: Aundrea E. Rockhold
(Event Coordinator’s Name)
18601 S. Main Street. Carson Ca. 90248
(Enter Event Coordinator’s address (i.e., city hall, corporate yard, or specific park address)
Email: arockhold@carsonca.gov
(Enter event coordinator’s email address)
Should you have any questions, please feel free to contact the staff member listed below .
Truly,
Aundrea Rockhold
(Name)
Rec. Center Supervisor II
(Title)
532227.5 CFN AS OF 3/14/2023
Checklist
Before submitting your application packet make sure each of the below
indicated items have been attached or completed.
(FOR COMMUNITY SERVICES OFFICE USE ONLY)
x Service Provider Application Agreement
< Invoice for Future Event Date!
=.
* Business License (if applicable)
rN Proof of Insurance/Certificate of Insurance
Waiver, Release, Hold Harmless, Agreement Not to
Sue, Indemnification, and Photo Release
Current Copy of W-9 Form (if not on file already) B
B
lk
* The date of the Event shall be listed on the Invoice for Future Event Date (IFED). If the Service Provider Application is
approved, then the IFED will be processed as an invoice for services rendered for the Event. No payment will be made
until the conclusion of the Event, at earliest.
532227.5 CFN AS OF 3/14/2023
8/7/2024
( “A
Plo ‘ips Salle Ave-
(Company Address)
L.A, CA Foor]
(City, State ZIP)
Insurance Requirements
Dear LA LA
(Enter Provider’s Name)
Please be advised pursuant to your desire to work with the City of Carson, you are required to
submit the following:
Y Compliant Certificates of Liability Insurance (to be maintained for the duration of services
against claims which may arise from or in connection with the services), evidencing the
coverage(s) as indicated below.
Certificates of insurance, as well as additional insured and waiver of subrogation
endorsements in favor of the City, must be submitted in their entirety before any services
are provided or the event takes place. Failure to submit such required forms shall be cause
for City of Carson to reject or terminate any service provider application agreement.
The City of Carson reserves the right to modify these requirements based on the nature of the
risk, prior events, insurance coverage, or other special requirements.
MINIMUM SCOPE AND LIMIT OF INSURANCE
General Liability Insurance: Coverage shall be at least as broad as Insurance Services Form
CG 00 O01 covering CGL on an “occurrence” basis, including property damage, bodily injury
and personal & advertising injury with limits no less than $1,000,000 per occurrence and
$2,000,000 aggregate.
Additional Insured Status
The City of Carson, and its elected and appointed officials, employees, volunteers and agents, are
to be covered as additional insureds with respect to liability arising out of their work or
operations performed at or on behalf of the City-sponsored event including materials, parts, or
equipment furnished in connection with the event.
532227.5 CFN AS OF 3/14/2023
City of Carson
Community Services Department
Service Provider Application Agreement
Check one (staff use):
| | Carson Event Center| _| Human Services Recreation [| Transportation
Cajun&Blues White Linen Affair . 701 E. Carson Sl. Carson September 9, 2023 t: Event Location: Event Date:
LALA Second Liners
Even
Name of Service Provider:
Business Form/Entity Type (if individual, sole proprietorship, corporation, or limited liability
company, specify here):
oH) Te anit ai ony
=) oe Type (if general partnership, limited partnership, limited liability partnership,
or other, specify here):
CQ) Van 2ak4 ow
ominitioniy State of Incorporation (if applicable): ( Ay
Type of Service. Live Performance
Contact Person. GAN Collins Sr Phone #: (310) 400-2323
Emer. Contact; Kim Collins Phone #; (310) 927-1693
Billing Address; 9461 La Salle Ave
Number Street
Los Angeles CA 90047
City State ZIP
Proof of Insurance (check one)? [Vlyes [No
If NO, please complete the attached insurance waiver form.
Special Instructions/Notes:
(X ) will perform 3 5-8 min Live sets at the upcoming White Linen Cajun Blues Fest. ( X) should arrive at least 1.5 hours before
schedule performance time(TBD) for load in and setup. Please forward stage plot and tech rider for Sound Co. (X) will receive
payment for White Linen Cajun Blues Fest on the day of the event 9/9/2023 . Payment will be in check made to Vendor name above.
532227.5 CFN AS OF 3/14/2023
Please list any special concerns in the section below. Please note, that the City of Carson is not responsible
for any Hotel, Transportation, or Per Diem expense. All these cost fall under the responsibility of the Performer.
If Service Provider wishes to request any special accommodation needed to facilitate provision of the
services, please identify it here or contact the staff member referenced on Page 1 of this application:
N/A
Total Service Fee $500.00
NOTE: If service provider is unable to provide the services as proposed or requested or the City
of Carson cancels the service for any reason, the associated fees will not be paid.
[remainder of page intentionally left blank]
532227.5 CFN AS OF 3/14/2023
Further Terms of Service Provider Application Agreement:
The undersigned signatory of Service Provider (Service Provider being the above-referenced person
or entity seeking to provide services at the above-referenced event, including all its officers, agents,
employees and volunteers) hereby represents and warrants that he or she is duly authorized by
Service Provider to execute and deliver this application on behalf of Service Provider, and that by so
executing this application, and in consideration for the City’s review of this application, Service
Provider is bound by these terms.
Service Provider understands and agrees to comply with the City’s “Service Provider Rules &
Regulations,” which are set forth below and incorporated herein by this reference.
Service Provider agrees to indemnify and release City in connection with its proposed services in
accordance with the “Waiver, Release, Hold Harmless, Agreement Not to Sue, Indemnification, and
Photo Release” submitted concurrently herewith.
Service Provider agrees to maintain all required insurance coverages and comply with all associated
insurance requirements as set forth on the above “Insurance Requirements” page, which is
incorporated herein by reference. Service Provider agrees that all required policies shall contain, or
be endorsed to contain, an agreement by Service Provider to waive all rights of subrogation and
contribution against the City, its elected or appointed officers, officials, employees and agents, for all
losses and liabilities paid under the terms of any policy which arise from the activities or operations
of, or the services performed by, Service Provider, regardless of any prior, concurrent, or subsequent
non-active negligence by the City.
In the event there is more than one person or entity named in this Service Provider Application
Agreement as the Service Provider, then all obligations, liabilities, covenants and conditions
hereunder shall be joint and several.
This Service Provider Application Agreement, unless and until accepted, approved, and executed by
the City Manager or designee, is only an application for provision of services to City, and does not
constitute an approval or authorization for Service Provider to perform or provide any service to City.
Neither Service Provider nor any of its agents or employees shall be deemed agents or employees of
the City, nor a member of a joint enterprise with the City. Neither Service Provider nor any of its
agents or employees shall at any time or in any manner represent that Service Provider or any of its
agents or employees are agents or employees of City, or that it is a member of a joint enterprise with
City. Subject to the requirements of this Service Provider Application Agreement, neither the City
nor any of its employees shall have any control over the manner, mode or means by which Service
Provider, its agents or employees, perform the services set forth herein.
In the event that part of this Agreement is declared invalid or unenforceable by a valid judgment or
decree of a court of competent jurisdiction, such invalidity or unenforceability shall not affect any of
532227.5 CFN AS OF 3-14-2023
the remaining portions of this Agreement which are hereby declared as severable and shall be
interpreted to carry out the intent of the parties hereunder.
Service Provider acknowledges that the City of Carson’s consideration of Service Provider’s
application to provide the above-referenced services is on the express condition that Service Provider
represents and warrants that it is and will be in compliance with all applicable restrictions on the use
of intellectual property, including copyright laws, in connection with the services proposed to be
provided. Service Provider shall indemnify, defend, and hold harmless the City against any penalties,
claims, or liabilities arising from or in connection with Service Provider’s noncompliance with same.
The undersigned, on behalf of Service Provider, agrees that Service Provider seeks and is willing to
provide the above-referenced service(s) on the date and time of the above-referenced event.
This Service Provider Application Agreement has been executed on the dates written below.
APPLICATION SUBMISSION (wet signature required; no electronic signatures):
SERVICE PROVIDER: LA LA
Vi (th bey 7d 8/7/2023
(Signature of Service Provider's Authored Reffresentative) (Date)
Sean Collins, Sr
(Printed Name of Service Provider’s Authorized Representative)
(Space below this line for City use only)
APPLICATION APPROVAL:
CITY OF CARSON
il 4-b-JF _ CY (Signfafe of City Manager or Designee) (Date)
532227.5 CFN AS OF 3-14-2023
Service Provider Rules & Regulations
1, SERVICE PROVIDER APPLICATION: Upon acceptance, approval, and execution of a
service provider application by the City of Carson (“City”), these rules and provisions shall
become binding and a part of the Service Provider Application Agreement between the applicant
(being the entity providing a service to City as specified in the service provider application),
including its officers, employees, agents and volunteers (“Provider”), on the one hand, and the
City, on the other hand. Any additions and amendments thereto that may be established or put
into effect by the City, and provided in wmiting to the Provider, shall also become binding and a
part of the Service Provider Application Agreement.
2. PAYMENT/CANCELLATION: If the Provider is unable to perform or cannot provide the
services as requested, or the City cancels the service for any reason, the associated fees for
service will not be paid.
3. CANCELLATION: No refunds will be given unless the subject event is cancelled by the
City’s Community Services Department. Applications may be denied or events cancelled in
favor of City programs.
4. PROPERTY LOSS OR DAMAGES: The City is not responsible for any damage to, loss or
theft of the Provider’s property, or that of Provider’s agents, employees or invitees.
5. CHARACTER OF ENTERTAINMENT: The Provider shall observe, obey and comply with
all applicable local, state and federal laws, and all applicable policies, rules, regulations and
terms and conditions governing use of City facilities. The Provider will forfeit all rents or other
fees paid if ejected from premises for violations of same. Ejection shall not release Provider
from any obligations for the payment of rents or other fees not yet paid under such permit or
additionally incurred. The policy of the City is to serve the public in the best possible manner.
The Provider shall at all times cooperate to this end.
The policies, rules, regulations and conditions governing use of City facilities are subject to
change without notice to Provider unless the change affects a permit already issued to Provider.
Provider shall be solely responsible for the orderly conduct of all persons using the premises by
its invitation, either expressed or implied, during all times covered by the Service Provider
Application Agreement. The City reserves the right to eject or cause to be ejected from the
premises any person or persons due to unlawful conduct.
6. RESPONSIBILITY: The Provider shall provide all material, equipment, and personnel
necessary for provision of the service described in this agreement.
7. MOVE-IN/MOVE-OUT: Move-in to the event area will be set for each venue. Unless
otherwise stated, Provider will be required to keep its area fully set up and manned until the
event is officially over. Please note that these times are subject to change.
8. SAFETY: Standing on chairs, tables or other rental equipment is prohibited. This equipment is
not engineered to support your weight. The City of Carson, its employees, agents, or officers will
not be responsible for injuries or falls caused by the improper use of furniture. Please assist in
our efforts to provide a SAFE WORKING ENVIRONMENT.
532227.5 CFN AS OF 3-14-2023
9. VOLUME/LIGHT CONTROL: The City reserves the right to regulate the volume or intensity
of any and all noise or light generating mechanisms (including, but not limited to, loudspeakers,
radios, television sets, musical instruments, entertainers, or blinking or flashing lights) in the
reasonable judgment of the City.
10. FLAMMABLE MATERIALS - All decorations, props and electrical equipment must be
fireproof or of fire retardant materials, must meet City requirements and are subject to removal.
Candles and other open flame devices will not be permitted except as authorized on this
agreement; subject to Fire Department regulations.
11. COPYRIGHT INFORMATION: Provider is responsible for licensing fees as required by
law. Provider may be subject to legal action for the use, display or sale of any item using any
copyrighted and/or trademarked name or logo which has not been specifically authorized under
license from the trademark holder.
12. PERMITS AND LICENSE: Provider shall procure at its own cost and expense all the
required licenses and permits applicable to Provider’s use or activity .
13. OBLIGATION FOR CLEANLINESS: Provider agrees that the facility and any other
surrounding City property (including parking lots) used by the Provider must be left in a clean
and orderly condition (equal to or better than the condition existing prior to the event). If
additional maintenance is required, other than the normal cleaning process, the Provider will be
charged additional fees based on the cost of such maintenance.
14, DISPUTES: All points not covered by the Service Provider Rules & Regulations are subject
to the decision of the appropriate City representative.
15. FLOOR MANAGEMENT: The City will appoint a Floor Manager who is authorized to
enforce these rules and regulations.
16. SPACE ASSIGNMENT: Event space is assigned to providers at the sole discretion of the
City. Concerns regarding competitive or specific types of providers should be communicated to
the City at the time of application.
17. RULE CHANGES: The City reserves the right to make reasonable changes to the foregoing
rules, event hours and move-in/move-out arrangements at any time without notice to Provider,
unless the change affects a permit already issued to Provider.
532227.5 CFN AS OF 3-14-2023
Waiver, Release, Hold Harmless, Agreement Not to Sue and Indemnification 10
I, Sean Collins, Sr _, (“individual”) [on behalf of
LALA (“Exhibitor”), and as a bona fide agent of Exhibitor duly authorized to execute this
Waiver, Release, Hold Harmless, Agreement Not to Sue and Indemnification agreement (“Agreement”) on behalf of Exhibitor]
Gndividual and Exhibitor hereinafter collectively referred to as “Signatory,” and the term “Signatory” includes Exhibitor’s officers,
officials, employees, agents and volunteers), seek acceptance by the City of Carson of an application ‘to provide services in/at
White Linen Cajun Blues Fest (“Event”) on 9/9/2023 (“Date’’).
Signatory understands that accidents, illnesses, and injuries can arise out of the Event; knowing the risks, nevertheless, and in
consideration of the acceptance of an application to provide a service at the Event on the Date, Signatory hereby waives, releases
and discharges the City of Carson, its elected and appointed officers, officials, employees, agents and volunteers (collectively
“City,” and individually, “City Party”), and from and against any and all claims or liabilities to Signatory or any other person or
entity, including but not limited to claims or liabilities for bodily injury, illness, death, or property damage, arising out of or
connected in any way with Signatory’s participation in, presence at, or performance of services at or for the Event, even though
that liability may arise out of negligence or carelessness on the part of City, and Signatory agrees to waive its rights to make any
such claims through any action or proceeding against the City or any City Party. However, Signatory understands that this paragraph
is not intended to release any party from any act or omission of “gross negligence.”
Signatory hereby grants City the right to photograph or video-record Signatory during or in connection with the Event, and to use
Signatory’s photographed or video-recorded likeness, and any image, silhouette, or- reproduction of the voice or appearance of
Signatory taken during or in connection with the Event (“Likeness”), for any purpose, including publicity and promotion of City
and its events, and creation or production of materials in any for for such purpose, with no claim of entitlement to any license fee
or royalty of any kind from City. Signatory hereby waives any right to the intellectual property of Signatory’s Likeness.
Signatory further agrees to indemnify, defend and hold harmless City and each City Party from and against any and all claims,
liabilities, losses, damages, expenses, and costs (including without limitation costs and fees of litigation) of every nature (including,
but not limited to, property damage, bodily injury, or death), whether imposed by law or otherwise, sustained or alleged to be
sustained by any person or entity (whether they be members of the public visiting the Event, employees of the City, other Exhibitors
at the Event, or otherwise), occurring at, arising from, or connected with Signatory’s preparation or performance of services at the
Event, Signatory’s actions, inactions, or use of facilities at the Event, or any equipment, machinery or items displayed or used by
the Signatory at or for the Event, except for such claim, liability, loss, damage, expense, or cost which was caused by the sole
negligence or willful misconduct of the City.
In giving the foregoing releases and waivers, Signatory expressly waives any and all rights conferred upon it by the provisions of
California Civil Code Section 1542, which Signatory understands reads as follows:
“A general release does not extend to claims that the creditor or releasing party does not know or suspect to exist in his or her favor
at the time of executing the release and that, if known by him or her, would have materially affected his or her settlement with the
debtor or released party.”
This waiver shall be effective as a bar to any and all actions, fees, damages, losses, claims, liabilities and demands of whatsoever
character, nature and kind, that are known or unknown, or suspected or unsuspected, that may arise from or relate in any way to
Signatory’s participation in the Event.
This Agreement shall be binding on Signatory’s successors, heirs and assigns, and shall not expire. No oral representations,
statements or inducements, apart from this written form, have been made with regard to the subject matter of this form. If any
portion of this form is declared invalid by a court of competent jurisdiction, the remainder shall continue in full force and effect.
By signing below, Signatory acknowledges and represents that it has read and understands the above, and that it voluntarily agrees
to its terms.
By signing below, Sjzhatory acknowledges and represents,that it has read and understands the above, and that is voluntarily
agrees to its terms it
SIGNED: WY Mh yt : =F ra
NAME: Sean Collins Sr |
ORGANIZATION:LA LA __
DATE: 8/7/2023
01007.0001/781805.1 AS OF 3-14-2023
Please note: The City of Carson’s own insurance will cover the City’s liability but will not cover an
Entertainer’s liability. All service providers (including entertainers) are still required to carry
insurance. We must require this because it is a condition of the City’s Excess insurance policy.
Acknowledgement:
1. |am an entertainer that will perform at the City of Carson
Cajun & Blues White Linen Affair Avent.
2. | am confirming that | and my business do not have commercial general liability insurance as
required by the City of Carson but am still interested to provide services at the
Cajun & Blues White Linen Affair event.
3. | acknowledge and agree that in the event of a loss the City of Carson or its insurance carrier will
not provide coverage to me or to my business.
4. | further acknowledge and agree that in the event of a loss resulting from my or my business’
wrongful or negligent acts, the City of Carson or its insurer will seek to recover its financial loss
from me or my business. | will cooperate in every way with the said recovery efforts.
5. The City of Carson may approve this request or may reject it at its discretion.
Signed: Hore Cibbe— MA.
pate. 9/7/2023
TAPCC- KL (5576)
PO BOX 286
BURLINGTON, NC 27216
Phone: (800) 334-5579
Fax: (336) 584-8880
SSS ES a
To: Rosalba Ramirez * BINDER *
08/07/2023
Attn: Rosalba Ramirez
rramirez2@farmersagent.com/(800) 334-5579
Renewal Of: NEW From: Melissa Selvaggio
mselvaggio@gotapco.com/Ext 8210
Insured: LALA
Mailing 9461 LA SALLE AVE Address: 1 OS ANGELES, CA 90047
Thank you for your order to bind. We appreciate your business! We have bound the below coverage. Policy to Follow Shortly
POLICY INFORMATION
COMMERCIAL LIABILITY POLICY
Policy Number: SE 1086820 09/09/2023 to 09/11/2023
Policy Period:
Carrier: United States Liability Insurance Company
Status: Admitted
A.M. Best Rating: At++ (Superior) - Xi
COVERAGE PART PREMIUM
Commercial Liability $250.00
Each Occurrence Limit $1,000,000
Personal & Advertising Injury Limit (Any One Person/Organization) $1,000,000
Medical Expense Limit (Any One Person) $1,000
Damages To Premises Rented To You (Any One Premises) $100,000
Products/Completed Operatlons Aggregate Limit See L-535
General Aggregate Limit $2,000,000
POLICY PREMIUM $250.00
ADDITIONAL COSTS
Wholesaler Broker Fee $75.00
TOTAL $325.00
Location of All Covered Special Event(s}
1-701 E. Carson St, Carson, CA 90745
APPLICABLE FORMS & ENDORSEMENTS
The following forms apply to the Commercial Liability coverage part
Please contact us with any questions regarding the terminology used or the coverages provided, Page 1 of 2
€G0001 12/07
CG2107 05/14
CG2136 03/05
CG2144 07/98
IL0047 11/98
1L0270 07/20
Commercial General Liability Coverage Farm
Exclusion - Access Or Disclosure Of Confidential Or
Personal Information And Data-Related Liability -
Limited Bodily Injury Exception Not Included
Exclusion - New Entities
Limitation Of Coverage To Designated Premises Or
Project
Common Policy Conditions
California Changes - Cancellation and Nonrenewal
CG0068 03/09
CG2109 06/15
CG2139 10/93
CG2147 12/07
110021 09/08
Jackel 07/19
Recording And Distribution Of Material Or
Information In Violation Of Law Exclusion
Exclusion - Unmanned Aircraft
Contractual Liability Limitation
Employment-Related Practices Exclusion
Nuclear Energy Liability Exclusion Endorsement
Policy Jackel
L535 03/15 Exclusion - Products-Completed Operations
L 427 01/20 Exclusion for Fireworks and Other Pyrotechnic
Devices Hazard Other Than Food Or Beverage Products
L-206 02/11 Fully Earned Premium Endorsement L-224 40/10 Punilive Or Exemplary Damages Exclusion
L-387 03/06 €xclusion - Mechanical Rides L-423 02/11 Exclusion For Structure Coflapse
L+428 04/15 Absolute Firearms Exclusion L-526 01/15 Absolute War Or Terrorism Exclusion
L-536 09/09 Exclusion - Participation In Athletic Activity, Physical L-599 40/12 Absolute Exclusion for Pollution, Organic
Activity Or Sports _ Pathogen, Silica, Asbestos and Lead wilh a Hostile
Fire Exception
L-G06 02/11 Exclusion For Injury To Performers, Enlertainers L-607 02/11 Exclusion For Climbing, Rebounding And
And Participants Interactive Games And Devices
L-609 02/14 Animal Exclusfon L-610 44/04 Expanded Definition Of Bodily Injury
L-656 02/06 Extension Of Coverage - Committee Members L-686 10/12 Absolute Exclusion for Liquor and Other Related
Liability
L-816 11/18 Amendments of Conditions - Limits of {nsurance L-820 12/18 Special Events Blanket Additional Insured
Under Multiple Coverage Parts Endorsement
LLQ 102 02/15
LLQ368 08/10
SPE 300 05/09
TRIAON 12/20
Event Vendor, Exhibitor And Contractor Exclusion
Separation Of Insureds Clarification Endorsement
Special Events Property Damage Amendment
Disclosure Notice of Terrorism Insurance Coverage
LLQ101 08/06
Notice-Unmanned
Aircraft-GL 05/16
SPE 312 03/15
Expanded Definition Of Employee
Advisory Notice To Policyholders
Who Is An Insured
Please cantac| us with any questions regarding the terminology used or the coverages provided. Page 2 of 2
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FRAUD WARNING: -
Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance or statement of claim containing any materially false information, or conceals for the purpose of
misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime,
and subjects such person to criminal and civil penalties.
South Carolina Cancellation Notice
The insurer can cancel this policy for which you are applying without cause during the first ninety days. Thal is the
STATE FRAUD STATEMENTS
Alabama Fraud Statement
“Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly
presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or
confinement in prison, or any combination thereof." Arizona Fraud Statement
“For your protection, Arizona law requires the following statement to appear on this form. Any
person who knowingly presents a false or fraudulent claim for payment or a loss is subject to
criminal and civil penalties." ARS Statute 20-466.03
California Fraud Statement
"For your protection California law requires the following to appear on this form. Any person who knowingly presents
a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and
confinement in state prison."
Colorado Fraud Statement
“It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for
the purpose of defrauding or altempting to defraud the company. Penalties may include imprisonment, fines, denial
of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly
provides false, incomplete, or misleading facts or information to a policy holder or claimant for the purpose of
defrauding or attempting fo defraud the policyholder or claimant with regard to a settlement or award payable from
the insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory
agencies." (C.R.S.A. statute 10-1-128.}
Delaware Fraud Statement
"Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of claim
containing any false, incomplete or misleading information is guilty of a felony."
District of Columbia Fraud Statement
"WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding
the insurer or any: other person. Penalties include imprisonment and/or fines, In addition, an insurer may deny
insurance benefits if false information materially related to a claim was provided by the applicant."
Florida Fraud Statement
"Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an
application containing any false, incomplete or misleading information is guilty of a felony of the third degree."
Louisiana Fraud Statement
“Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly
presents false information in an application for insurance is guilty of a crime and may be subject to fines and
confinement in prison."
Maine Fraud Statement
"It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the
purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits."
Maryland Fraud Statement
"Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who
knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be
subject to fines and confinement in prison."
New Jersey Fraud Statement
“Any person who includes any false or misleading information on an application for an insurance policy is subject to
criminal and civil penalties.”
New York Fraud Statement
“Any person who knowingly and with intent to defraud any insurance company or other person, files an application
for insurance or statement of claim containing any materially false information, or conceals for the purpose of
misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime
and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for
each such violation."
Ohio Fraud Statement
“Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an
application or files a claim containing a false or deceptive statement is guilty of insurance fraud."
Oklahoma Fraud Statement
"WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim
for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a
felony.”
Pennsylvania Fraud Statement
"Any person who knowingly and with intent to defraud any insurance company or other person files an application
for insurance or statement of claim containing any materially false information or conceals for the purpose of
misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime
and subjects such person to criminal and civil penalties."
Rhode Island Fraud Statement
"Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly
presents false information in an application for insurance is guilty of a crime and may be subject to fines and
confinement in prison."
Tennessee Fraud Statement
"It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the
purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits."
Texas Fraud Statement
"Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may
be subject to fines and confinement in state prison."
Virginia Fraud Statement
"It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the
purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits."
Washington Fraud Statement
It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company.
include imprisonment, fines and denial of insurance benefits.
Penalties
3060 South Church Sueet. P.O. Box 286
Burlington, North Carolina 27216
(Local) 336-584-8892
(Toll-Free) 800-324-5579
{FAX} 336-584-8880
(Claims FAX) 336-538-0094
CA License# 0778135
Insured State Account Number Effective Date —_‘ Expiration Date ‘
Lala CA UGFKM-Z 9/9/2023 9/11/2023 :
Base i Insp/Pol State Tax | Tax Stamp |Total Premium Less Net Due Amount Balance
Premium Fee Fee Commission TAPCO Paid
$250.00 $75.00 $0.00 0.00 $325.00 $0.00 $325.00 $0.00 $325.00
Agency# 520718 TAPCO accepts Visa, :
Rosalba Ramirez MasterCard, Discover, American 2 11953 S VERMONT AVE Express and electronic (ACH) e LOS ANGELES , CA 30044 checks. : :
In accordance with your instructions, we have bound coverage with the company shown on the quote proposal. A net premlum check in the amount :
of $325.00 is due within 12 days of the effective date shown above. Please return a copy of this binder with your net premium check to TAPCO, 4
This premium is based on the information obtained. The premium is subject to change if the underwriting or rating hb
information differs. a
No Flat Cancellations Allowed. [
Policy Fees are 100% earned. i
The Premium is 100% Earned :
100% earned accounts are not eligible for financing. E
If you would like to pay by Visa, MasterCard, Discover, American Express, or Electronic (ACH) Check, please see the
attached Payment Information Form OR log into the TAPCO Broker Gateway to see additional options of making
payment net of your commission. The credit card transactions are processed by ePay (a third party vendor) and ePay
retains a 2.60% fee on each transaction. There is not additional fee for an ACH transaction.
Otherwise, mail a check to our home office for processing.
If you have any questions, please contact our Accounting Department at 1-800-334-5579 and choose option 3.
BINDER INVOICE - ORIGINAL A
UGFKM-Z UGFKM
Request for Taxpayer
Identification Number and Certification
Department of the Treasury Internal Revenue Service > Go to www.irs.gov/FormW9 for instructions and the latest information.
1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.
Louisiana to Los Angeles Organizing Committee
2 Business name/disregarded entity name, if different from above
LA LA
3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the | 4 Exemptions (codes apply only to
following seven boxes. certain entities, not individuals; see
instructions on page 3):
Give Form to the
requester. Do not
send to the IRS.
W-9 Form
(Rev. October 2018)
(1) individual/sole proprietor or O C Corporation O S Corporation CO Partnership LJ Trustestate
single-member LLC Exempt payee code (if any)
C Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) >
Note: Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check | Exemption from FATCA reporting
LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is code (if an
another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC that e ¥}
Print
or
type.
Other (see instructions) >
is disregarded from the owner should check the appropriate box for the tax classification of Its owner.
Organization (Applies to accounts maintained outside the U.S.) * 5 Address (number, street, and apt. or suite no.) See instructions,
9461 La Salle Avenue
See
Specific
Instructions
on
page
3.
Requester's name and address (optional)
City of Carson
6 City, state, and ZIP cade
Los Angeles, CA 90047
Attn: Aundrea E. Rockhold
18601 S. Main St 7 List account number(s) here (optional) a OA BA! oO GdaTson, CA FULZ46
Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid
backup withholding. For individuals, this is generally your social security number (SSN). However, for a
resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other - -
entities, it is your employer identification number (EIN). If you do not have a number, ses How to geta
TIN, later.
Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and
Number To Give the Requester for guidelines on whose number to enter.
| Social security number
or
[ Employer identification number |
9/5] -| 4) 4/347 [8 |.6]5
ews Certification
Under penalties of perjury, | certify that:
1, The number shown on this form is my correct taxpayer identification number (or | am waiting for a number to be issued to me); and
2, |am not subject to backup withholding because: (a) | am exempt from backup withholding, or (b) | have not been notified by the Internal Revenue
Service (IRS) that | am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that | am
no longer subject to backup withholding; and
3. lama U.S. citizen or other U.S. person (defined below); and
4, The FATCA code(s) entered on this form (if any) Indicating that | am exempt from FATCA reporting is correct.
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because
you have failed to report all interest and dividends on your tax ratum. For real estate transactions, item 2 does not apply. For mortgage interest paid,
acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments
other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part Il, later.
Sign Signature of
Here U.S. persan > B_ (he
General Instructions
Section references are to the Internal Revenue Code unless otherwise
noted.
Future developments. For the latest information about developments
related to Form W-9 and its instructions, such as legislation enacted
after they were published, go to www.irs.gov/FormW9,
Purpose of Form
An individual or entity (Form W-9 requester) who is required to file an
information return with the IRS must obtain your correct taxpayer
identification number (TIN) which may be your social security number
(SSN), individual taxpayer identification number (ITIN), adoption
taxpayer identification number (ATIN), or employer identification number
(EIN), to report on an information return the amount paid to you, or other
amount reportable on an information return. Examples of information
retums include, but are not limited to, the following.
e Form 1099-INT (interest eamed or paid)
Cat. No, 10231X
Date > &- 7-KO RZ
e Form 1099-DIV (dividends, including those from stocks or mutual
funds)
* Form 1099-MISC (various types of income, prizes, awards, or gross
proceeds)
¢ Form 1099-B (stock or mutual fund sales and certain other
transactions by brokers)
e Form 1099-S (proceeds from real estate transactions)
¢ Form 1099-K (merchant card and third party network transactions)
* Form 1098 (home mortgage interest), 1098-E (student loan interest),
1098-T (tuition)
¢ Form 1099-C (canceled debt)
° Form 1099-A (acquisition or abandonment of secured property)
Use Form W-9 only if you are a U.S. person (including a resident
alien), to provide your correct TIN.
ff you do not return Form W-9 to the requester with a TIN, you might
be subject to backup withholding. See What is backup withholding,
later.
Form W-9 (Rev. 10-2018)
Leeann eee
LALA
9461 LASALLE AVE
LOS ANGELES, CA90047
310 400 2323
C/O SEAN COLLINS SR.
Invoice/Quote
Submitted on 08/10/2022
Invoice for Payable to Invoice #
LALA 202394
City of Carson
Project Due date
CAJUN & BLUES WHITE LINEN AFFAIR 9/9/2023
Description Qty Unit price Total price
LALA SECOND LINERS 1 $500.00 $500.00
$0.00
$0.00
Notes: Subtotal $500.00
701 E. CARSON ST. PARKING LOT 9/9/2023 6PM Adjustments
$5 00 .00