PROOF OF INSURANCE (2020 - 2020) CLOSEDCERTIFICATE OF LI . o 10W �'""
ABILITY INSURANCE � ° �
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(8), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPholder In If the certificate holdIs an ADDITIONAL INSURED, the pollcy(Ns) must be endorsed N SUBROGATION 18 WANED, subjed to
the terns and conditions of On policy, certain policies may require an endonternerrt. A stalanwit on tills cordficallo does not confer rlghte to the
cortificale holder In lieu of such end a). `
A.
PRoollcln GedeaL Shwp
Epitome Insurance Solutions .951-801-4151 I
9590 Magnolia Ave. Suite B ved6opliomeinsurorloexom
Riverside _ CA 92503INSUMMAROMMOOVEtAft MAIC e
rrBnlRn1 A : SeaffIY National Irwxwm Con"M 16979
I SSRI o Namm a : -%=* Neft Irw rev= Comperry 19876
Daniel R. Tron DBA ONE WAY PAINT AND DESIGN aBwnaec:
`812 Whidng St. BwlRaie D
MONISM 8:
El Segundo CA W245
I
P. .,
COVERAGES CERTIFICATE.,
NUMBER:
M N
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 VITTH RESPECT TO W *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 SHOYIM MAY HAVE BEEN REDUCED BY PAID CLAIMS.
TYPE OPpeURANCE ppY lAlriwa. .
I..�
LSSTB
COMMERCIAL GENERAL LIABafTYEACM
OCCURRBiCE •
1,000.600
CLAWS -MADE ® OCCUR
Wyk ivKtNILLI
r i!
10p.000
MED EXP IMr an powf
5.000
A X,
NA187718900
tuoermte ttloertazo PERSONAL a ADVILAMY s
1.000.000_
GEr L AGGKGATE LaaTAPPLIES PEW
GMRALAOM1115G ►TE f
$000,000 .
POLICY1:1.� ❑ LOC
X PRODUCTS-COrPIOPAOO s
1.000.000 -
••
O ma,
f
AurolrosLe LwlLnr ...
.... ......
�
LIMIT :
ANY AUTO
SODILY INJURY (Pr paeaa s
V�
ALL OKAYED
AUTOS
80*M(J .ED -
AUTOS
BODILY VMURY (Per aoNdut) S
HIRED AUTOS
AUTD
T°ROPErCIY I s
$
�.
UreRELU1 L1AB
I�
OCCUR
RENCE
a EACH OCCURs
EXCESSU"
CLAN044AM
AGOREGA TE f
:,
DED RETENTION s
TIONAND
010410YOWUAVIUTY YVN
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AW IETORWARTN UTA'
OFFICEMER E1tC1,UOEW N / A
VYC0716818055
11ABIlO1B I7 tA78/1020 E.L.EACH ACCIDENT s
1,000.00D"
j
;
In rill
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DrSEASE - EA EMPL f
O�p
1.000.000!
deKtho Ln OPERATIONSE.L
FrnO.., ..,.below
., .. , E.L. DISEASE - POLICY LOST V $ „ „
2.000.000,
OF
I WILL BE T REPAINTING EXISTING RESIDENTIAL HOMES ABOUT 80% AND COMMERCIAL BUILDINGS ABOUT 10'16
Y
CERTIFICATE MOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE
CITY of El Segundo THE MWIRATiON DATE THEREOF, NOTICE WILL BE DELIVERED IN
350 Main SL ACCORDANCE WWRH THE POLICY PROVISIONS,
B Segundo, CA 90245
J
/IITTXDR® REPIIBea1rTATIVE .. ,
I aej Sham
G 198&2014 ACORD CORPORATION. All
AC01EI 25 (201401) The ACORD name and logo an rsplatsred marks of ACORD
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY
BLANKET ADDITIONAL INSUREDS -
OWNERS, LESSEES OR CONTRACTORS
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Policy Number: NA167718900
.......................
Named Insured
DANIEL TRON
ONE WAY PAINT & DESIGN
Name of Person or Organization:
Endorsement Effective: 4/30/2020
Countersignedy;
SCHEDULE
111_�
12:01 a.m.
Any person or organization that the named insured is obligated by virtue of a written contract or
agreement to provide insurance such as is afforded by this policy.
Location:
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations
as applicable to this endorsement.)
A. Section II —Who Is An Insured is amended to include as an insured the person or organization
shown in the Schedule, but only to the extent that the person or organization shown in the
Schedule is held liable for your acts or omissions arising out of your ongoing operations
performed for that insured.
B. With respect to the insurance afforded to these additional insureds, the following exclusion is
added:
2. Exclusions
This insurance does not apply to "bodily injury" or "property damage" occurring after:
(1) All work, including materials, parts or equipment furnished in connection with such
work, on the project (other than service, maintenance or repairs) to be performed by
or on behalf of the additional insured(s) at the site of the covered operations has been
completed; or
(2) That portion of "your work" out of which the injury or damage arises has been put to
its intended use by any person or organization other than another contractor or
subcontractor engaged in performing operations for a principal as a part of the same
project.
C. The words "you" and "your" refer to the Named Insured shown in the Declarations.
D. "Your work" means work or operations performed by you or on your behalf; and materials, parts
or equipment furnished in connection with such work or operations.
Primary Wording
If required by written contract or agreement: Such insurance as is afforded by this policy shall be
primary insurance, and any insurance or self-insurance maintained by the above additional
insured(s) shall be excess of the insurance afforded to the named insured and shall not contribute
to it.
Waiver of Subrogation
If required by written contract or agreement: We waive any right of recovery we may have against
an entity that is an additional insured per the terms of this endorsement because of payments we
make for injury or damage arising out of "your work" done under a contract with that person or
organization.
49-0108 07 11 May Include Copyrighted Material of Insurance Services Offices, Inc. Page 1 of 1
Used with permission
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AFFORDAND DANIEL R BARBARA A
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TRON
612 WHITING ST
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oluN, I„I Ilw
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90245-2946
EL SEGUNDO CA „I
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Email Address: barbaraPonewaypaint com i°
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Barbara A Gafford
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Daniel R Tron
Vehicles VIN
VeFokgle Lo,Waobi„ f"anpe Company
Ll�lJhglsler
,
1 2007 Toyota Tundra STBBT54117S451003
EI Segundo CA 90245 Toyota Financial
Servi
2 2005 Cad STS 1G6DC67A550214289
EI Segundo CA 90245 ces
3 2003 BMW 3251 WBAAZ334X3KP79178 EI Se undo CA 90245 m ,
. 9.
Coveraqes” ,Limits and/or Deductibles Vehicle 1 Vehicle 2
, Vehicle 3
Bodily Injury Liability
Each Person/Each Occurrence
State Minimum $15,000/$30,000
Propertyams«
D.... .............,.....,.,.....«...
age Liability
State Minimum $5,000
Uninsured & Un11 derinsured Motorists
Each Person/Each Occurrence
...,...,.....
r -e- ............. ........ .....«« .,.,...........
...
Comprehensive
$100,000/$300,000
$121.30 $64,60 $70.80
$50,000 $107.20 $60.60 $59.40
$100,000/$300,000 $65.30 $35.20 $37.90
$500 Ded $24.10 $26.30 $28.30
Collision ped . ,„« . . , $105.60
$500 Ded%Waiver « ” $135.«50.........,.,« „$91.00
..-..........,«.,«..«,..«, „
Six Month Premium Per Vehicle $453.40 $292.30 $287.40
Total Six Month Premium $1,033.10
'Coverage applies where a premium or $0.00 is shown for a vehicle.
If you elect to pay your premium in installments, you may be subject to an additional fee for each installment. The fee
amount will be shown on your billing statements and is subject to change.
Continued on Beck
DEC PAGE (0314) (Page 1 of 4) Renewal Poky Page 11 of"52
., . � a Ilul� no
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:
(_J 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 El Segundo is executed. My workers' compensation insurance
carrier and policy number are:
Carrier Policy Number Expiration Date
Name of Agent Phone #
(4) 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 become subject to the workers' compensation provisions of Labor Code § 3700 1 must
immediately comply wi thou rovi 9 - ns ement will automatically become void.
Signature of Applicant a 4r ("� Date
�9 PP
Print Name
t
Agreement for:
Dated:
Reviewed by: _--