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PROOF OF INSURANCE (2022 - 2023) CLOSEDA c'e Dlr `64�° CERTIFICATE OF LIABILITY INSURANCE DATE (MMMD/YYYY) 03/11 /2022 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 INS'URER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the pollcy(ies) must be endorsed. If SUBROGATIONIS 'WAIVED, subject to the terms and conditions of the pollcy, certain policies may require an endorsement. A statement on this certificate does not confer ri hts to the certificate holder in lieu of such endorsei-e-1- PRODUCER CONTACT NAME: UNITED DIRECT INSURANCE SVCS INC 72250427 PHONE (800)1805-0787 FAX i818)898-68 6 15255 VENTURA BLVD SUITE 704 IArC, N'e„ EXt)` IA C. No): ENCINO CA 91436 E-MAIL ADDRESS: INSURED LA UNIFORMS & TAILORING, INC. DBA LA UNIFORMS & TAILORING 15625 HAWTHORNE BLVD STE D LAWNDALE CA 90260-2667 INSURER(S) AFFORDING COVERAGE NAIL# INSURER A: Sentinel Insurance Company Ltd. 11000 INSURER B: INSURER C °„ INSURER D : INSURER E INSURER F : I+UVtKAUtb CERTIFICATE NUMBER: REW THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE tNSLJ INDICATEMNOTWITH STANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY risR TYPE OF INSURANCE ADDL SURR PO41CY EFF PO0r-V exP POLICY NUMBER rfflm r E�General ERCIAL GENERAL LIABpLI"rY LAIMS-MADE MOCCUR.. Liability A X 72 SBA BE0351 04/14/2022 04/14/2023 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY [] PRO-� ] LOG JECT LX OTHER AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS HIRED NON -OWNED 'AUTOS AUTOS UMBRELLA LIAR +.+a.�..vn EXCESS LIAR CLAIMS - MADE ED RETENTION $ W—CRI<E.RS COMPENSATION AND EMPLOVERe' LIABILITY ANY YIN PROPRIETORIPARTNER/EXECUTME NIA OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under A DATA BREACH - BUS INC & EX 72 SBA BE0351 04/14/2022 04/14/2023 EXP DESCRIKION OPOPERATIONS7LOCA'FIONSIYERICLES(ACOFRD 101, Additional Remarks Schedule, may be attached If more spat Those usual to the Insured's Operations. Certificate holder is an additional Insured per Additional Insured: O Person or Organization Form SS4170 and Additional Insured: Owners, Lessees or Contractors: Completed ON NUMBER RED NAMED ABOVE FOR THE POLICY PERIOD DOCUMENT WITH RESPECT TO WHICH THIS SCRIBED HEREIN IS SUBJECT TO ALL THE PAID CLAIMS, LIMITS EACH OCCURRENCE $1100D,000 DAMAGE TOAEWEO $1,000,000 MED EXP (Any one person) $10,000 PERSONAL & ADV IIdJuR'Y GENERAL AGGREGATE$i2,000,000'' ' PRODUCTS - COMPIOP AGG $2, Do0,OOD O-CkMaINE.DSIN�GkF1.,pa4TF9., 57 BODILY INJURY (Per person) BODILY INJURY (Per accident) PrtOPEiRTY tJAl4AGE (Per acdoeu&I EACH OCCURRENCE AGGREGATE PER ClTH- SIAruTO ER. E.L. EACH ACCIDENT E.L. DISEASE -EA EMPLOYEE .. E.L. DISEASE - POLICY LIMIT Limit $50„000 e is required) wners, Lessees, or Contractors: Scheduled Operations form SS4171„ attached to this El 5egund0 Police Department SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELL11 ED 348 MAIN ST BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED EL SEGUNDO CA 90245-3813 IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD El 5egund0 Police Department SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELL11 ED 348 MAIN ST BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED EL SEGUNDO CA 90245-3813 IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 72 SBA BE0351 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNER, LESSEES OR CONTRACTOR LOC 01 BLDG 001 EL SEGUNDO POLICE DEPARTMENT 348 MAIN STREET, EL SEGUNDO, CA 9024S NUMBER OF JOB LOCATIONS 1 DESCRIPTION OF COMPLETED OPERATIONS ALL PROJECT OF THE NAMED INSURED Form IH 12 00 11 85 T SEQ. NO. 001 Printed in U.S.A, Page 001 Process Date: 01 / 2 6/2 2 Expiration Date: 04 /14 /23 FARMERS Auto Insurance Declaration Page INSURANCE Policy Number: 20059-16-08 Effective: 2/26/2022 12:01 AM Expiration: 6/28/2022 12:01 AM Nomed insured(s): MukhtarRaza Underwritten Ely: Farmers insurance Exchange 6301 Owens mouth Ave. Woodland Hills, CA91367 Premiums/Fees Full -term Premium (excluding fees) $2,405.20 Prorated Premium (2/24/2022 - 6/28/2022) $1,633.51 Fee for this transaction $30.00 Total forthis'fransaction $1,663.51 This is not a bill. Information on this declaration is effective 2/24/2022. Household Drivers All persons who drive or will occasionally bed rivin a any of the cars on the policy should be listed below. If anyone ismissing or needs to be added, such as a newly licensed driver, you should contact your agent or the company to add that person before they begin to drive anyofthe cars covered on the policy. Name Driver Status Name DriverStotus Mukhtar Raza Covered Shakiba Raza Covered Covered Excluded NI Excluded Excluded Vehicle Information Veh. # Year/Make/Model/VIN Coverage Deductible Limit 1 2020 Honda Cr-V Hybrid 4D 4Wd Tourin Comprehensive: $500 Collision: $500 2 2021Volkswagen NewJetta4D1.4TS/SE/R- Comprehensive: $500 Collision: $500 Coverage Information Coverage Bodily Injury Liability Property Damage Liability Permissive User Limit of Liability" Limits (oppficobic ro alf vehicles) $250,000 each person $500,000 each accident $100,000 each accident Limited (See Permissive User Limit of Liability in your policy) Premiums by Vehicle Vehicle 1 Vehicle 2 $453.90 $286.10 $283.80 $282.00 Included Included Medical Coverage Not Covered Not Covered Uninsured Motorist Bodily $250,000 each person $85.70 $135,50 Injury $500,000 each accident Comprehensive $48.10 $30.80 farn•1ers.com Policy No.20059-16-06 Ouestions? Manageyouraccount: Cell your a,^erir Violet C Tava at (818) Go to vmvv>.farmers.com to access 800 4226 or ernaO your account any time' vtavakofieaiPLrr�7�r ze:cyr�nt..�>rn 56-6176 2nd Edition 3-19 2/25/2022 Page 1 of 3 IMPORTANT - THIS IS NOT A BILL. SENn Kin MnNpv ueu— HOME OFFICE SAN FRANCISCO POLICY DECLARATIONS CALIFORNIA WORKERS' COMPENSATION AND EMPLOYER'S LIABILITY POLICY THESE DECLARATIONS ARE A PART OF THE WORKERS' COMPENSATION POLICY INDICATED HEREON. ................... THIS INSURANCE IS EFFECTIVE FROM 12:01 A.M., PACIFIC STANDARD TIME 1-20-22 TO 1-20-23 AND SHALL AUTOMATICALLY RENEW EACH 1-20 UNTIL CANCELLED CONTINUOUS POLICY 9311627-22 LA UNIFORM & TAILORING INC. DEPOSIT PREMIUM $0.00 15625 HAWTHORNE BLVD SUITE D LAWNDALE, CALIF 90260 MINIMUM PREMIUM $630.00 PREMIUM ADJUSTMENT PERIOD QUARTERLY N SC NAME OF EMPLOYER- LA UNIFORM & TAILORING INC. TRADE NAMES- LA UNIFORM & TAILORING INC. LOCATIONS- 15625 HAWTHORNE BLVD SUITE D LAWNDALE CA 90260 1. WORKERS' COMPENSATION INSURANCE - PART ONE OF THIS POLICY APPLIES TO THE WORKERS' COMPENSATION LAWS OF THE STATE OF CALIFORNIA. 2. EMPLOYER'S LIABILITY INSURANCE - PART TWO OF THIS POLICY APPLIES TO LIABILITY UNDER THE LAWS OF THE STATE OF CALIFORNIA. THE LIMIT OF OUR LIABILITY INCLUDING DEFENSE COSTS UNDER PART TWO IS, $1,000,000 CODE NO. PRINCIPAL WORK AND RATES EFFECTIVE FROM 01-20-22 TO 01-20-23 INTERIM PREMIUM BASE BILLING BASIS RATE RATE* 8008-1 STORES --CLOTHING, SHOES, LINENS OR 28980 3.28 3.55 FABRIC PRODUCTS--RETAIL--INCLUDING ALTERATION DEPARTMENT *******BUREAU NOTE INFORMATION******** SHAKIBA RAZA P,S,T 100 FEIN 842203910 TOTAL ESTIMATED ANNUAL PREMIUM $1,028 ;OUNTERSIGNED AND ISSUED AT SAN FRANCJ&W olf ►RY 21, 2022 POLICY L PAGE 1 OF 3 SCIF FORM 10961A (REV.7-2014)