PROOF OF INSURANCE (2022) CLOSED.A� '"C "A'°'S�0 DATE (MMIDD/_IYm
i wRV CERTIFICATE OF LIABILITY INSURANCE os/za/zozl
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 have ADDITIONAL INSURED provisions or 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 endorsemen s .
PRODUCER
CONTACT Ed Barnhart
CFI Ed BarnhartNAM
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PHONE (31D)322�911 SAX (310)615-1000
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502 Main St
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mhart.b9@statefarm.. edba .cwm
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_- AFFORDING COVERAGE NAIC 0
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ElSegundo CA 90245
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INSURER A, State Farm General Insurance Company 25151
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INSURED
INSURER B r
Carol Well
INSURER C f
INSURER D
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INSURER. E
ElSegundo CA 90245
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 j
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.
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POLICY EFF j POLICY EXP
LTR TYPE OF INSURANCE G POLICY NUMBER
l hJMITS
COMMERCIAL GENERAL, LIABILITY
! EACH OCCURRENCE
I $ 1,000,000
DAMAGE TOR E NTED
300,000
CLAIMS -MADE .J OCCUR
PRFMISES�,F�r1 cxxurrertcn)
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MED EXP (An one person)
S 5.000
A j Y 92-J2-0525-2
09/01/2021 09/01/2022 PERSONAL & ADV INJURY
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GeNI AGGREGATE'. LIMIT APPLIES PER:
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GENERAL AGGREGATE
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$ 2,000 000
Pf,IyI D'Y JECT LOC
�_T�IODYC TS • COMPIOP AGG
S 2.000 000
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AUTOMOBILE LIABILITY
C MMNED SlaiGw c LIMIT
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ANY AUTO
I BODILY INJURY (Per person)
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OWNED J SCHEDULED
AUTOS ONLY I AUTOS
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BODILY INJURY (Per accid, enq
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HIRED NON -OWNED
AUTOS ONLYf AUTOS ONLY
-. OPERTY DAMAGE
PR
S
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UMBRELLA LIAR j OCCUR
EACH OCGURRENCE.
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WORKERS
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DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101. Additional Remarks Schedule, may be attached If more space is required)
Additional Insured: The City of El Segundo, its officers, officials, employees, agents and volunteers.
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
The City of El Segundo
350 Main St AUTHORIZED REPRESENTATIVE
ElSegundo CA 90245 O'l 4
@ 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
1001486 132849.13 04-22-2020
CAMFoRNIA
INSURANCE Ai D
state avIn Mutual AiftomObft5 "ra ce Company AAl1TL
1 UR E;p 5 W L iC.4R0Lf�r VOL
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POLICY MI)MHERP26 oeSS-A29-75F 111E < AN' 29 2022
YA 2008 MA11E TOYOTA VIN � 1354-A7S
MjDfL CAMPY
AGENT ELF BARNHART NAIC 25178
EHU1iBL 3tt1322-89t�
;Q(AEtAG ITS
° PIS Vuf7EG 1tY THE POLICY MEETST76 MINIMUM
LiA91LITY UM
pRESGffIE1EEi BY LAW.
COVER ES A G 0 G106 H f," IJ 1➢'I
SEE 9tLSftiiSE 5i8E FOR ERf LANATiON.
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.
affirm under penalty of perjury under the laws of California one of the following declarations:
L_) 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 El Segundo.
Policy No.
(_) 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 #
01 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
immediately comply with those' ievisions or the green ent will,a'tomaticalNybecome void.
9 pp M a.�..��" �nm .,..•, Date v
Signature of Applicant
Print Name
Agreement for: r
2-2-22
Dated:
Reviewed by: