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PROOF OF INSURANCE (2021 - 2022) CLOSEDC, DATE (MMIDD/YYYY) CERTIFICATE OF LIABILITY INSU NCE 02/19/2021 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 Fernando Valenzuela, Agent Lic#0759747 -NAA . � CONTACT H athe.M" SWIr1 State Farm Insurance 9 PHONE F �. E-MAIL �.. .. StateFarm 2700 International Blvd, Ste A ADORES H tter y rr1�„iz aist tefarm.gOrc, etl Oakland, CA 94601 _...............� INSURER(Sj AFFORDING COVERAGE _ �NAIC # ....._„ INSURED Juan Lopez JMYROB_......_. DBA Amistad Associates INsuREE C 6610 Barbara Dr. iNSURER9 _ ,,,, Sebastopol, CA 95472 INSURER F c�_.._w._._..........._.�.�.................... ___w �._..-...._...........� __._ 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. ADD — POLICY E'FF POLICY EXP INTR TYPE OF INSURANCE POLICY NUMBER MMIDDIYYYY ,MMIDD LIMITS GENERAL LIABILITY A Y 97-B4^1507-7 01/11/2021 01/11/2022 � EACH OCCURRENCE $ 2,000,OOQ COMMERCIAL GENERAL LIABILITY �AMIC�I= � RFMISFS„Fa,ocgyrrence .., $ _...rv... 100 0Q0 I x V CLAIMS -MADE EK OCCUR MED EXP (Any one person) .w � ... _ $ 5,000 ....._._. ._--- ...................... ...... ..�..... PERSONAL & ADV INJURY $ 2,000,000 .._ ....wa,.m. ........__..................�. !GENERAL AGGREGATE ___ ......_...___,........_..... ,.,....._...A $_._.,....,.,, 4,000,000 _,_...,, ., ._.._,.._._...._..._ ... G.E.N'L AGGREGATE LIM..... IT APPLIES PER: PRODUCTS-COMP/OPAGG $ 4,000,000 ..X.., .. _..._... POLICY PRC. LOC ..._........... ................ �� .....,........000,0....___.. $ A AuraMoslLE uAalurY 214 9766-004-05D 09/04/2020 09/04/2021 COMBINED LIMIT $ x ANY AUTO BODILY INJURY (Per person) $ 1,000,000 X ALL OWNED SCHEDULED AUTOS AUTOS .._._.w, BODILY INJURY (Per accident ) .,_,. $ 1,000,000 X NON -OWNED HIRED AUTOS AUTOS PROPERT' OAMAGE ..J.P�r Iarnpioyfnl} ._. ......... _.. $ 1,000,000 .$ UMBRELLA LIAB F OCCURRENCE $ COCCUR EXCESS LIAB IAlMS-MADE �" ARCH AGGREGATE $ DE.. I_v RETENTION$ $ WORKERS COMPENSATION WC STATU )470'I"FX» AND EMPLOYERS' LIABILITY Y / N '—"- V 5 ANY PROPRIETORIPARTNER/EXECUTIVE OFFICE/MEMBER EXCLUDED? � N/A E L EACH ACC DENT, ..... ....". , $ .'. ...""..". .....""........ '.... (Mandatory in NH) E.L. DISEASE EA EMPLOYE $ If yes, describe under '.. E.L DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHIC ES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) t.eee attached for additional insured endorsement for General Liability lrJ3iiltil*YY1lI4i01-1Ls1;4 1111111111VOIWI; Vn a 14 w11IN70 City of Ell Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Ell Segundo, CA 90245 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD 1001486 132849.8 01-23-2013 TH Policy No. 97-B41507-7 FE-6609 SECTION 11 ADDITIONAL INSURED ENDORSEMENT Policy No.: 97-B41507-7 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 "X" in the box. 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 I affirm under penalty of perjury under the laws of California one of the hallowing declarations, LJ I have and will maintain a cartift*9 of consent of Wf4psure for wo*ert comps nsafion, issued by the Director of Industrial Relations as provided for by Labor Code § 3700 for the perb(mnoe of the work set forth Me agreement with the City of El Segundo. Policy No. U I have and will maintain workers" oompensalion Insurance as r"Wred by Labor Code 4 3700 forthe 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. Name of Agent Policy NumlberlGxpirafion Date Phone * I certify that, In the performance of the work set forth in the agiree"pi with the City of El Segundo, I will not employ any pawn in any manner so as to become subject to the workers' oommImnsation laws of California, and agree that, it I should became subject to the workers' congorAtion provisions of Labor Code J 3700 1 must Immediate) con" with 669i��(vlsiona or 21 t will automatically becorne void. Z, Signature of Appliewl k= Date Print Norm Agreement for: 3Qmy) T � Lo I) ez- rilbi