PROOF OF INSURANCE (2020 - 2020) CLOSEDCERTIFICATE OF LIABILITY INSURANCE QA1`0/07/2019
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 polley(les) must be endorsed. If I SUBROGATION IS WAIVED, subjectt 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 ondorsernent(s).
PRODUCER Fernando Valenzuels, Agent Lk#0759747
CONTACT
_MMei- Heather Swino
State Farm insurance
PHONE
sWeftm 1238 30th Ave
"
ADDALESS: Heath'er.SWn.o,izavastatela,rm,com
Oakland, CA 94601
INSURCRISt AFFORDING COVERAGE NAJC I
INSURER A. State Fann General qw
INSURIM Juan Lopez
INSURER a.
DBA Amistad Associates
INSURER C
6610 Barbara Dr.
INSURER 0
Sebastopol, CA 95472
INSURER E.
INSURER F:
COVERAGE$ 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 CONTRACTOR OTHER DOCUMENT WTH RESPECT TO V"CH 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 [A SUBRII POLICY EMP I
LTR L TYPE OF INSURANCE POLICY NUMBER (M IMMIMM I Lear$
A GENERALLIABLITY Y 97434-1607-7 1 0111112019 0111112020 1 EACHOCCURPZNCE S 2,0100,000
Y �Vj B" 1 UAAIAU� W RtN I iw
COMMERCtAL GENERAL LtAMLITY PREWS15S (Ea oWunWw*$ IpNI S 100,000
X CLAIMS -MADE L OCCUR MED EXP (Any we Pawn) S 5,000
[PERSONAL & ADV INJURY j 2;000,0010
GENERAL AGGREGATE I 4,000,000
GERL AGGREGATE LIMIT APPLIES PER PRODUCTS -COMP" AGO S 4,000,000
F�
X POLICY F 9 LOG
C4 NII F-11 SINGLE LIMIT
A AUTOMOOILE LIABILITY 214 9760-004-06C 0910412019 0310412020
ANYALITO -BODILY INJURY (Pal pwa.)
ALL OWNED SCHEDULED
AUTOS X AUTOS od-m 5 1,000,000.
NOWOWNEDDAMAGE
r X HIREDAVF06 AUTOS i7— 1,000,000
— I I Pw Is
UMBRELLA LUIAB OCCLIR EACH OCCURRENCE S
EXCESS LIAS C -MADE ft
AGGGAT11
E
DEO RETENTION Z LA&S9`11
WORKERS COMPENSATIOU 14S7'ATU- I JOTH•l
AND FMPLOYMS'UABUITY VIN Y I IN15 ER I
ANY PROPRIETORIPARTNERIE)CECUTIVE EL EACH ACODENT EJ3.
OFFICENEMBER EXCLUDED? NIAF7
(Mandaf*ry In NH) E.LDISFASE-EAEMMOY
II Yes, dew" uNof E.L DISEASE - POLICY LIMIT � S
DESCRIPTION CIFOPERATIONS I LOCATIONS I VMMZ PAt..hACORD IOI,Addid.UIPMn.M.S.hod.lo, If m.. Va.. I. mquired)
Additional insured endorsement - City of El Segundo, its officials, officers, employees, volunteers, and agents
Please see attached for additional insured endorsement
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of El Segundo THE EXPIRATION DATE THEREOF, NOTICE WLL BE DELIVERED IN
350 Main Street ACCORDANCE WITH THE POLICY PROVISIONS.
El Segundo, CA 90245 A117TAY"
I
C131988-20 ACORD CORPORA -1`10N. All rights reserved.
ACORD 25 (2010106) The ACORD name and logo are registered marks of ACORD 1001486 132849.8 01-23-2013
IZAV Policy No.: 97-B41507-7 FE -6609
SECTION 11 ADDITIONAL INSURED ENDORSEMENT GC
Policy No.: 97-1341507-7
Named Insured: LOPEZ, JUAN
DBA AMISTAD ASSOCIATES
Additional Insured (include address):
City of El Segundo
350 Main Street
El Segundo, CA 90245
WHO IS AN INSURED, under SECTION 11 DESIGNATION OF INSURED, Is amended to include as
an insured the Additional Insured shown above, but only to the extent that liability is imposed on that
Additional Insured solely because of your work performed for that Additional Insured shown above.
Any insurance provided to the Additional Insured shall only apply with respect to a claim made or a
suit brought for damages for which you are provided coverage.
The Primary Insurance coverage below applies only when there is an ")C' in the box.
Z Primary insurance. The insurance provided to the Additional Insured shown above shall be
primary insurance. Any insurance carried by the Additional Insured shall be noncontributory
with respect to coverage provided to you.
All other policy provisions apply.
FE -6609 Printed In U.S.A.
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 ($700,000),
IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED
FOR IN LABOR CODE 9 3706, INTEREST, AND ATTORNEY'S FEES.
I affirm under penalty of perjury under the laws of California one of the folbDwing declarations;
have and will rnaintam a certificate of consent of set'f-insure for hers' compensation, issued by the Director
of Industrial Relations as provided for by Labor Code M 3700 fdr 'the parRmanoe of the work set forth the agreement
with the City of EI Segundo.
Policy No.
I have and will msintann workers' oompensation 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 Policy Nurnberl~xpiradon Date .
Name of Agent Phone.
G4 1 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 beoome subject to the workers' compensation Provisions of Labor Code § 3700 1 must
immediately complyr�with
J tih Na:'.,.P.. ,.u.,°�s.Wb.,o.., .n.., sthe
,.. or .. thfe. f. n.�,„..w.
...I,,. a��u,
�
maticaIfy become void.Date aleS' nature of Applicant
Print Name ,.�� '„ .. �... .... ...
Agreement for:k Q 'i r t T (, o l) ez- X16 4
Dated: -� o
Reviewed by: