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PROOF OF INSURANCE (2020 - 2020) CLOSED0 DA CERTIFICATE OF LIABILITY INSURANCE I TE (MMIDD/YYYY) 10/21/2019 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 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 TANIA RICHARDSON NAME L RICHARDSON INSURANCE AGENCY, INC StateFarm 17715 CRENSHAW BLVD TORRANCE, CA 90504 INSURED VISION ADELANTE DBA PARTY POSIES 1267 SARTORI AVE TORRANCE, CA 90505 PHONE EXt) 310-225-5600 310-323-8171 TAN IA 'Ac, Nat,310-323-8171 ADDRFM ESS, Tania.richardson t w5 statefarm com ADDRESS: P @ INSURER(S) AFFORDING COVERAGE INSURER A:State Farm General Insurance Company INSURER B � INSURER C INSURER D 7 INSURER E INSURER F NAIC # 25151 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, INSIiAN D>p, POLICY NUMBER IMMIDDY� POLICY EXf' LIMITS LTR TYPE OF INSURANCE 1 (MOLICY XP _ AX EACH OCCURRENCE $ 1,000,000 COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR X BUSINESS GEN'L AGGREGATE LIMIT APPLIES PER: (POLICYRuECr✓ I, LOC r 0,TrC.rR; AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS UMBRELLA LIAB OCCUR EXCESS LIAB CLAIMS -MADE DED RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE ji� OFFICER/MEMBER EXCLUDED? p NIA (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below OAMA'[,,C' Y0 RtN 0 t U „PREMISES iraocc:uueflvoa $ 92 -B7 -P154-9 G 07/01/2019 07/01/2020 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG S2,000,000 „ 5 COMBINED SINGL1. LIM" i[Fa arx7dLM) BODILY INJURY (Per person) 5 BODILY INJURY (Per accident) 5 PROPERTY L AMAGC $ $ EACH OCCURRENCE $ AGGREGATE $ $ PER CPTH- , STATUTE C.R E L. EACH ACCIDENT $ E L DISEASE - EA r&p Fgj)YEE $ E DISEASE - POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) AUTOMATIC RENEWAL - If the Policy Period is shown as 12 months, this policy will be renewed automatically subject to the premiums, rules and forms in effect for each succeeding policy period, If this policy is terminated, we will give you the Mortgagee written notice in compliance with the policy provisions or as required by law: 10 days before the effective date of cancellation if we cancel for nonpayment of premium; 30 days before the effective date of cancellation if we cancel for any other reason. 350 MAIN ST EL SEGUNDO CA 90245-3895 CERTIFICATE HOLDER THE CITY OF EL SEGUNDO ITS OFFICERS, OFFICIALS, EMPLOYEES, AGENTS, & VOLUNTEERS ATTN CITY CLERK CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 350 MAIN ST EL SEGUNDO CA 90245-3895 AUTHORIZED REPRESENTATIVE •"" @1988-1 4 ACO D CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD 1001486 132849.9 02-04-2014 CH Policy No. 92 B7P154 9 0919—FA75 N CMP -47861 Page 1 of 2 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, CMP -4786.1 ADDITIONAL INSURED — OWNERS, LESSEES, OR CONTRACTORS (Scheduled) This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM SCHEDULE Policy Number: 92 B7P154 9 Named Insured: VISION ADELANTE DBA PARTY POSIES 1267 SARTORI AVE TORRANCE CA 90501-2720 Name And Address Of Additional Insured Person Or Organization: THE CITY OF EL SEGUNDO ITS OFFICERS, OFFICIALS, EMPLOYEES AGENTS & VOLUNTEERS ATTN CITY CLERK 350 MAIN ST EL SEGUNDO CA 90245 3895 SECTION II — WHO IS AN INSURED of SECTION II — LIABILITY is amended to in- clude, as an additional insured, any person or organization shown in the Schedule, but only with respect to liability for "bodily injury", "property damage", or "personal and advertis- ing injury" caused, in whole or in part, by: a. Ongoing Operations (1) Your acts or omissions; or (2) The acts or omissions of those acting on your behalf; in the performance of your ongoing opera- tions for that additional insured; or b. Products – Completed Operations "Your work" performed for that additional insured and included in the "products - completed operations hazard". However, Paragraph 1. above is subject to the following: a. The insurance afforded to the additional insured only applies to the extent permit- ted by law; b. If coverage provided to the additional in- sured is required by a contract or agree- ment, the insurance provided to the additional insured will not be broader than that which you are required by the contract or agreement to provide for such addition- al insured; and c. If the contract or agreement between you and the additional insured is governed by California Civil Code Section 2782 or 2782.05, the insurance provided to the additional insured is the lesser of that which: (1) Is allowed for the satisfaction of a de- fense or indemnity obligation by Cali- fornia Civil Code Section 2782 or 2782.05 for your sole liability; or (2) You are required by contract or agreement to provide for such addi- tional insured. We have no duty to defend or indemnify the additional insured under this endorsement un- til a claim or "suit" is tendered to us. ©, Copyright, State Farm Mutual Automobile Insurance Company, 2013 Includes copyrighted material of Insurance Services Office, Inc., with its permission. CONTINUED CMP -4786.1 Page 2 of 2 2. Any insurance provided to the additional in- (3) The nature and location of any injury sured shall only apply with respect to a claim or damage arising out of the "occur - made or a "suit" brought for damages for rence" or offense; which you are provided coverage. b. Tender the defense and indemnity of any 3. With respect to the insurance afforded to the claim or "suit" to us and to all other insur- additional insured, the following is added to ers who may have insurance potentially SECTION II — LIMITS OF INSURANCE: available to the additional insured; and If coverage provided to the additional insured is required by contract or agreement, the most we will pay on behalf of the additional insured will be the lesser of the amount of insurance: a. Required by the contract or agreement; or b. Available under the applicable Limits Of Insurance shown in the Declarations. This endorsement shall not increase the ap- plicable Limits Of Insurance shown in the Declarations. 4. With respect to the insurance afforded to the additional insured, the following is added to Paragraph 3. Duties In The Event Of Occur- rence, Offense, Claim Or Suit of SECTION II — GENERAL CONDITIONS: The additional insured must: a. See to it that we are notified as soon as practicable of an 'occurrence" or an of- fense which may result in a claim. To the extent possible, notice should include: c. Agree to make available any other insur- ance the additional insured has for de- fense or damages for which we would provide coverage under SECTION II — LIABILITY. S. With respect to the insurance afforded the ad- ditional insured, the following replaces SEC- TION II —LIABILITY of Paragraph 7. Other Insurance of SECTION I AND SECTION II — COMMON POLICY CONDITIONS: a. This insurance is primary to and will not seek contribution from any other insurance available to the additional insured, provided that the additional insured is a named in- sured under such other insurance. b. Regardless of any agreement between you and the additional insured, this insur- ance is excess over any other insurance whether primary, excess, contingent or on any other basis for which the additional in- sured has been added as an additional in- sured on other policies. (1) How, when and where the `occur- There will be no refund of premium in the event rence" or offense took place; this endorsement is cancelled. (2) The names and addresses of any in- jured persons and witnesses; and All other policy provisions apply. CMP -4786.1 1007033 148011 08-21-2014 ©, Copyright, State Farm Mutual Automobile Insurance Company, 2013 Includes copyrighted material of Insurance Services Office, Inc., with its permission State Farm Mutual Automobile Insurance Company PO Box 853922 Richardson, TX 75085-3922 AT2 A-0919 A PARDO, ANITA DBA PARTY POSIES FLORAL 1311 SARTORI AVE TORRANCE CA 90501-2720 Policy Number: 143 8164 -CO2 -75B Policy Period: September 2, 2019 to March 2, 2020 Vehicle: 1995 FORD CLUB WAGON Principal Driver: ANITA PARDO Your auto insurance rates are impacted by the mileage your vehicle is driven. To ensure we've priced our insurance coverage accurately based on the number of miles you drive, we obtained valid odometer readings for this vehicle through a third party provider and/or from you. Annual mileage was determined using this data and applied. Please contact your State Farm agent with questions. Policy Number: 143 8164-0O2-7513 Prepared July 16, 2019 1004583 AStateFarm AUTO RENEWAL PREMIUM PAID: $945.63 DO NOT . Your premium is billed through the State Farm Payment Plan State Farm Payment Plan Number: 0383247323 Your State Farm Agent L RICHARDSON INSURANCE AGY INC Office: 310-225-5600 Address: 17715 CRENSHAW BLVD TORRANCE, CA 90504-4120 If you have anew or different car, have added any drivers, orhave moved, please contact your agent. Thank you for choosing State Farm. When you provide a check as payment, you authorize us either to use information from your check to make a one-time electronic fund transfer from your account or to process the payment as a check transaction. When we use information from your check to make an electronic fund transfer, funds may be withdrawn from your account as soon as the same day we receive your payment, and you will not receive your check back from your financial institution. Page number 1 of 5 143562 202 01-15-2018 Your auto insurance premium is $945.63. Did you know you may qualify for a discount? Call State Farm' Agent L RICHARDSON INSURANCE AGY INC at 310-225-5600 -Not all discounts are available in every state, and drscount amounts may vary by state. Review your policy information carefully. If anything is incorrect, or if there are any changes to your vehicle information, please let us know right away. Vehicle Identification Vehicle Description Number (VIN) 1995 FORD CLUB WAGON 1FMEE111-13SHA69833 Original cost of customization none or up to $1,000. Other Household Vehicle(s) Your premium may be influenced by other State Farm policies that currently insure the following vehicle(s) in your household: 2010 DODGE JOURNEY Who principally drives this vehicle? How is this vehicle normally used? ANITA PARDO, a single female, who will Business. have 35 years of driving experience as of September 02, 2019. The premium on the expiring policy term was based on over 7,500 miles per year. The premium on the renewal policy term was based on 10,700 miles per year. The premium for this renewal was determined using an annual mileage this vehicle is expected to be driven that was developed from information we obtained or was provided by you. Please contact us if you expect your annual mileage to change over the next year. Assigned Driver(s) The following driver(s) are assigned to the vehicle(s) on this policy, Driving Experience as of Name September 02, 2019 ANITA PARDO 35 years ........... ................ .__..1111,.._......... ERIK A GONZALEZ VASQUEZ 20 years Other Household Driver(s) In addition to the Principal Driver(s) and Assigned Driver(s), your premium may be influenced by the drivers shown below and other individuals permitted to drive your vehicle. This list does not extend or expand coverage beyond that contained in this automobile policy. The drivers listed below are the drivers reported to us that most frequently drive other vehicles in your household. ROSANA TORRES Premium Adjustment Each year, we review our medical payments and personal injury protection coverages claim experience to determine the vehicle safety discount that is applied to each make and model. In addition, we review the comprehensive, collision, bodily injury and property damage claim experience annually to determine which makes and models have earned decreases or increases from State Farm's standard rates. If any changes result from our reviews, adjustments are reflected in the rates shown on this renewal notice. Marital Gender Status Female Single ._............ ._m Male Married Policy Number: 143 8164 -CO2 -75B Page number 2 of 5 Prepared July 16, 2019 Principal Driver & Assigned Drivers For each automobile, the Principal Driver is the individual who most frequently drives it. Each driver is designated as an Assigned Driver on the household automobile that they most frequently drive. Your premium may be influenced by the information shown for these drivers. COVERAGE AND LIMITS See yourpolicyforan explanation of these coverages. A Liability Bodily Injury 100,0001300,000 Property Damage 100,000 D 500 Deductible Comprehensive ......................... G 500 Deductible Collision H Emergency Road Service U Uninsured Motor Vehicle Bodily Injury 30,000/60,000 U1 Uninsured Motor Vehicle Property Damage Total Premium If any coverage you carry is changed to give broader protection with no additional premium charge, we will give DISCOUNTS These adjustments have already been applied to your premium Multiple Line Multicar Driving Safety Record _..........._................... California Good Driver Loyalty Total Discounts Driving Safety Record Rating Plan Your driving safety record, along with other rating factors, determines what you pay for Liability, Medical Payments, Comprehensive, Collision, and Uninsured Motor Vehicle Coverages. Policyholders with no accidents and convictions pay less than those with accidents and convictions. The Driving Safety Record Rate Level that is assigned to your policy moves up, down, or stays the same every policy renewal, depending upon your driving record. For every 12 Policy Number: 143 8164 -CO2 -75B Prepared July 16, 2019 $739.51 $20.15 $136 ....... $2.45 $42.58 $463 $945.63 you the broader protection without issuing a new policy, starting on the date we adopt the broader protection. months since the renewal following the occurrence of a chargeable accident or the conviction of a minor violation, the initial assigned Driver Record Level for that chargeable accident or conviction shall be lowered by 1 level. For each 12 month period since the conviction of a major violation, the initial assigned Driver Record Level for that conviction shall be lowered by 2 levels. The Rate Level is increased if there are subsequent chargeable accidents or convictions. (continued on next page) Page number 3 of 5 Definition of Chargeable Accidents Chargeable accidents for new business are those which resulted in bodily injury or death or in payment(s) by an insurer due to damage to any property in the amount of more than $1000. For accidents occurring prior to December 11, 2011, an accident shall be chargeable provided it resulted in death or in payment(s) by an insurer due to damage to any property in the amount of more than $750. For applicants without prior insurance at the time of the accident, an accident shall be chargeable provided it resulted in damage to any property in the amount of more than $1000 (more than $750 if the accident occurred prior to December 11, 2011). If any information on this renewal notice is incomplete or inaccurate, or if you want to confirm the information we have in our records, please contact your agent. For additional �� ' Chargeable accidents for renewal business are those which resulted in bodily injury or death or State Farm claim payments totaling more than $1000 (more than $750 for accidents occurring prior to December 11, 2011) under property damage liability coverage and collision coverage combined. For more information about the rating plan, please contact your State Farm agent. Your Multiple Line Discount has decreased. For additional information, please contact your agent. Driving Safety Record Rate Level 5 information regarding discounts or coverages, see your State Farm agent or visit statefarm.com®. Annual Mileage We want to tell you about a change to how your premium will be calculated. Beginning with this renewal, we will obtain odometer readings annually through a third party vendor to determine your annual mileage. This eliminates the need for customer -provided odometer readings. When applicable, this new process replaced any previous mileage -based rating on your policy. If you have questions, please contact your State Farm agent. Important Notice e in r Premium State Farm works hard to offer you the best combination of price, service, and protection. The amount you pay for automobile insurance is determined by many factors including: • The coverage you have • Where you live • The kind of car you drive • How the car is used • Who drives the car Any premium adjustment is reflected on this Auto Renewal. If you have any questions, please contact your agent. Buying a new c? Remember to contact r i When you buy an additional car or one that replaces a car already on your policy, you need to report the change to your agent promptly. Even though the dealership you purchased the car from may offer to notify your agent or insurance company, you, as the named insured, are responsible for reporting all changes to your auto policy. By contacting your agent, you can help: • avoid any complications or lack of coverage in the event of an accident or loss, • avoid insurance verification problems with a lienholder, the police, or the department of motor vehicles, and • ensure that you receive any new discounts you may be entitled to. Your current State Farm policy automatically provides certain coverages for a new or replacement car for up to a specified, limited number of days after you take possession of the car. Please refer to your policy for the number of days that applies in your state. (continued on next page) Policy Number: 143 8164 -CO2 -75B Page number 4 of 5 Prepared July 16, 2019 Fry �M %� I If you have any questions about coverage for a newly acquired car, please contact your State Farm agent. Disclaimer: This message is provided for informational purposes only and does not grant any insurance coverage. The terms and conditions of coverage are set forth in your State Farm Car Policy booklet, the most recently issued Declarations Page, and any applicable endorsements. Policy Number: 143 8164 -CO2 -75B Page number 5 of 5 Prepared July 16, 2019 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: U 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. U 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 Policy Number Expiration Date Name of Agent Phone # (�} I certify that, in the performance of the work set forth in the agreement with the City of EI Segundo, I will not e ploy any person in any maAsct as to become subject to the workers' compensation laws of California, and agree that, if I should becomto the workers' compensation provisions of Labor Code § 3700 1 must immediately comply with thosens or the agreement will automatically become void. Signature of Aplicant Date '" 5 Print Name Agreement for: ' 1 R�?o:90 A" — Dated Reviewed by: