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PROOF OF INSURANCE (2022) CLOSEDCERTIFICATE OF LIABILITY INSURANCE DATE (MMI°DIYYYY) 09/18/2021 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 CONTACT NAMSEAN ERICKSON E: _ SIRE INSURANCE SERVICES PHONE H E EMI) 310 985 1234 FAX Nip 888 881 2239 12019 WILSHIRE BLVD p"°PRI ,, SEAN@SREFAM COM ,_ LOS ANGELES, CA 90025 INSURER(SI AFFORDING COVERAGE NAIC # INSURERA: SCOTTSDALE INSURANCE COMPANY 41297 INSURED INSURER B SAUL GONZALEZ DBA SWIM WITH ME INSURERC INSURER D ..,� INSURER E . INSURER F : 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. ILR .. _... AOi X. SUBR POLICY TR TYPE OF INSURANCE POLICY NUMBER MMIDOfYYXY LIMITS GENERAL LIABILITY EACH OCCURRENCE S 1 ,000,000 ✓ '. ! AnOE rrvt 100,000 COMMERCIAL GENERAL LIABILITY PREMISES�Fa nrcurrencej $ CLAIMS -MADE ✓ OCCUR '... _MED EXP (Any one person) $ ® 5,000 A X CPS 7443280 09/25/2021 09/25/2022 PERSONAL & ADV INJURY $ 1,000,000 GENERALAGGREGATE S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: '... ". '.. PRODUCTS - COMP/OP AGO $ 2,000,000 '.. POLICY PR( LOC S AUTOMOBILE LIABILITY ._... COMBINED SINGLE LiMVT ANY AUTO BODILY INJURY (Per person) S . ALL OWNED SCHEDULED ,... BODILY INJURY (Per acc cident) S AUTOS NON -OWNED " PROF'Ef"yT7" DAMAGE $ HIRE6AUT0S AUTOS '.) „.,,(, ev �n4rtlK;r?I UMBRELLA LIAB '.... OCCUR '.. '.. EACH OCCURRENCE S EXCESS LIAB CLAIMS -MADE AGGREGATE S DIED '.. '.... RETENTION $ ''. ''. $ WORKERS COMPENSATION WC O AND EMPLOYERS' LIABILITY YIN „.,._, _, TOTi,)',l IITU '.,, ,,,,,,,, Td, ,,....,, ..._. .. ...... .............. „...... .., , ,,, ANY PROPRIETOR/PARTNER/EXECUTIVE E L EACH ACCIDENT S OFFICERIMEMBER EXCLUDED? NIA. (Mandatory in NH) E L DISEASE EA EMPLOYEE S j If yes, describe under .,.._._ DESCRIPTION OF OPERATIONS below I., E.L. DISEASE -POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) CERTIFICATE HOLDER NAMED AS ADDITIONAL INSURED PER FORM CG 2012 12 19 LOCATION: 2240 E. GRAND AVE„ EL SEGUNDO, CA 90245 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CITY OF EL SEGUNDO THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 3501 MAIN ST. ACCORDANCE WITH THE POLICY PROVISIONS. EL SEGUNDO, CA 90425 AUTHORIZED REPRESENTATIVE ACORD 25 (2010/05) @ 1988-2010 ACORD CORPORATION. All rights reserved.. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: CPS 7443280 COMMERCIAL GENERAL LIABILITY CG 20 12 12 19 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - STATE OR GOVERNMENTAL AGENCYU I `I It POLITICAL SUBDIVISION- PERMITS OR AUTHORIZATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE State Or Governmental Agency Or Subdivision Or Political Subdivision: THE CITY OF EL SEGUNDO, ITS OFFICERS, OFFICIALS, EMPLOYEES, AGENTS AND VOLUNTEERS Information r uired to complete this Schedule, if not shown above will be shown in the Declarations. I A. Section II — Who Is An Insured is amended to include as an additional insured any state or governmental agency or subdivision or political subdivision shown in the Schedule, subject to the following provisions: 1. This insurance applies only with respect to operations performed by you or on your behalf for which the state or governmental agency or subdivision or political subdivision has issued a permit or authorization. However: a. The insurance afforded to such additional insured only applies to the extent permitted by law; and b. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. 2. This insurance does not apply to: a. "Bodily injury", "property damage" or "personal and advertising injury" arising out of operations performed for the federal government, state or municipality; or b. "Bodily injury" or "property damage" included within the "products -completed operations hazard". B. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable limits of insurance; whichever is less. This endorsement shall not increase the applicable limits of insurance. CG 20 12 12 19 ©Insurance Services Office, Inc., 2018 Page 1 of 1 PCA State Fe rim ® Stiffefiariii Providing Insurance and Financial Services �.L, PO Box 853919 Richardson, TX 750953919 Attached as requested are your replacement insurance identification cards. If the attached cards are not accepted by a law enforcement agency or your Department of Motor Vehicle office, please contact your agent to receive additional assistance. Thank you for choosing State Farm for your insurance needs. ------------------------------------------ IMPORTANT - IDENTIFICATION CARDS STATE FARM to to r � to tefi'mrr CALIFORNIA THIS CARD MUST BE KEPI IN THE INSURED MOTOR INSURANCE CARD aft, VEHICLE FOR PRODUCTION UPON DEMAND. State Farm Mutual Automobile Insurance Company PO Box 853919 Richardson, TX 750853919 INSURED GONZALEZ, SAUL MUTL VOL POLICY NUMBER 4907980-AOS-75A EFFECTIVE YR 2009 MAKE TOYOTA JUL 05 2021 TO JAN 05 2022 MODEL PRERUNNER VIN AGENT 9W' " rS INS AGENCY INC 284C-A75 PHONE NAIC 25178 OC7VERA � .. P "'VIDED BY THE POLICY MEETS THE MINIMUM LIABILITY LIMITS IF YOU HAVE AN ACCIDENT - NOTIFY THE POLICE IMMEDIATELY 1. Get names, aldtbess", and phone numbers of persons'itwvolved and witnesses. Also gst dldvef license. numbers of persons mvotved and license plate nnumbatalatates of vetk ec 9. Don't admit fault or discuss the accident with anyone but Stele Farm or police. 3. Promptly notify your agent, log on to statefarm.com4l), or use the State Farm mobile Opp to file a claim. For EMERGENCY ROAD SEANCE use the Slate Farm mobile app, log on toslatefarmcom' or call 1-877427.5757. EXAMINE POLICY EXCLUSIONS CAREFULLY. MS FORM DOES NOT CONSTTTU7F ANY PART OF YOUR INSURANCE POLICY. How to identify your coverage. See policy for full name and definition A Liability H Emergency Road Service U Uninsured Motor Vehicle C Medical Payments L Physical Damage U1 Uninsured Motor Vehicle PD D Comprehensive R1 Car Rental and Travel Expenses Z Loss of Eamings G Collision S Death, Dismemberment and Loss of Sioht KEEP A CARD IN YOUR CAR. THIS CARD IS INVALID IF THE POLICY FOR WHICH IT WAS ISSUED LAPSES OR IS TERMINATED. KEEP YOUR CURRENT CARD UNTIL THE EFFECTIVE DATE OF THIS CARD. ONE COPY OF THIS FORM SHOULD BE CARRIED IN THE VEHICLE AT ALL TIMES, THE FORM MAY BE NEEDED AS EVIDENCE OF INSURANCE IN COURT. SUBMIT ONE CARD, OR A PHOTOCOPY OF A CARD, WITH YOUR VEHICLE REGISTRATION RENEWAL Emergency Road Service information is located on your insurance card. — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — —5 IMPORTANT - IDENTIFICATION CARDS STATE FARM trrtet-rirr ttet�trr rrr CALIFORNIA THIS CARD MUST BE KEPT IN THE INSURED MOTOR A. INSURANCE CARD VEHICLE FOR PRODUCTION UPON DEMAND. State Farm Mutual Automobile Insurance Company PO Box 8M19 Richardson TX 750953919 INSURED GONZALEZ,SAUL MUTL VOL POLICY NUMBER 4907980-AO5-75A EFFECTIVE YR 20" MAKE TOYOTA JUL 05 2021 TO JAN 05 2022 MODEL PRERUNNER VIN �I AGENT IGGS IINS AGE7ICY INC 284C-A75 PHONE NAIC 25178 COV PAAC P .Vjoen B HE POLICY MEETS SHE MIMMUM LIABILITY LIMITS IF YOU HAVE AN ACCIDENT - NOTIFY THE POLICE IMMEDIATELY 1. Get names, addtresscsi,. and phone numbers of personas imrotved and witnesses. Also get statesdrof Wenlolesortse numbers of persons iwofverl and ricense plate numberal,2. Don't admit fault or discuss the accident with arryone but State Farm or police. 3. Prompt.. rbellN your agent, log on to statefarm.comO, or use the State Farm mobile app to fife a lm. For EMERGENCY ROAD SERVICE use the State Farm mobile app, log on to statefarmcom, or call 1-877427-5757. EXAMINE POLICYEXCLUSJONS CAREFULLY. THIS FORM DOES NOT CONSTITUTE ANY PART OF YOUR INSURANCE POLICY, How to identify your coverage. See policy for full name and definition A Liability H Emergency Road Service U Uninsured Motor Vehicle C Medical Payments L Physical Damage U7 Uninsured Motor Vehicle PD D Comprehensive R1 Car Rental and Travel Expenses Z Loss of Earnings G Collision S Death, Dismemberment and KEEP A CARD IN YOUR CAR. THIS CARD IS INVALID IF THE POLICY FOR WHICH IT WAS ISSUED LAPSES OR IS TERMINATED. KEEP YOUR CURRENT CARD UNTIL THE EFFECTIVE DATE OF THIS CARD. ONE COPY OF THIS FORM SHOULD BE CARRIED IN THE VEHICLE AT ALL TIMES. THE FORM MAY BE NEEDED AS EVIDENCE OF INSURANCE IN COURT,. SUBMIT ONE CARD, OR A PHOTOCOPY OFA CARD, WITH YOUR VEHICLE REGISTRATION RENEWAL 143295.3 (oleccald), 01-15-20'18 Emergency Road Service information is located on your insurance card. MAY 28 2D21 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 affi under penalty of perjury under the laws of California one of the following declarations: 7I 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 El Segundo. Policy o. I have and will maintain workers' compensation insuranceas 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 # I certify that, in the performance of the work set forth in the agreement with the City of El 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 dN Signature of A. immediately comply with o r v� ons or the agreement will automatically become voi Date 10/15/21 Print Name Saul z I Agreement for:-Smo l Goo S u` ° ;'-t e- Dated: 10-20-21 i Reviewed by. Hank Lu