PROOF OF INSURANCE ()C!TY OF EL SEGUNDO
' ORKERS9 COINIPENSATION 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),
.NI ADDIT I N. " THE. COST OF COMPENSATION, DAMAGES AS PROVIDED
FOR I I Ali O (100E 37#��, INTEREST AND A.TTORNEiY`S FEES.
I affirm under ppnaity fir pet un,, under �w e flaws of California ore of the following ceclarations:
(_) I have and wiil maintai a certificate o" consent of self -insure for workers' compensation, issued by the Director
of Industrial Rtalatior s aG eI) Wdad for bv Labor 7or Code § 3?'W.9 for the performance of the work set forth the agreement
with the ity of E? 5egi i�ido.
Policy No.
(_} I have and wi±l rnair t?ir: workews' -. rr-nper%jJon Ins mince as required by Labor Code § 3700 for the performance
of the wori;_ for —hidn the agr5erF-ant wil^ *he City of E! e—gunco is executed. My workers' compensation insurance
carrier and policy number are.:
Carrier Policy Number Expiration Date
(dame o"Agerf Phone # ...
Of oer# v that: in 'ha work set forf;^ in the agreement with the City of El Segundo, I will not
employ ;any ner&7-r 1n anv1 .--1gnrq, ,n :7 L-0 be .ome subiecl o t1he workers' compensation laws of California, and
agree that'. If i should; :i2 :r:; ��,= si.bislci; "M thV worker,-,,,-,! ��mpensation provisions of Labor Code § 3700 1 must
im na#dia-te v Apr t=,yni t' oeq o ls�crs reern� r < u�ifi autornat4calhl became void.
Sig _ _ ".
Print Name
Agreement fat•: _ z ' ' , _.2, ..U.�1. 7 to 101im
Any -lire o�sC..:. , ,�� St ' ', ��r.�_.-........�
Dated: 8-11-2021
r 2
Reviewed by. '"