PROOF OF INSURANCE (2022) CLOSEDAC Rn' CERTIFICATE OF LIABILITY INSURANCE
LYam,,,,,.
DATE (MMIDD/YYYY)
03/15/2022
PRODUCER
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY
AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
Alberto O Ocon
CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE
828E Colorado St. Ste F
COVERAGE AFFORDED BY THE POLICIES BELOW.
Glendale, CA 912t.
Ph.(818)507-9705 Fax: (818) 662-9996
INSURERS AFFORDING COVERAGE
NAIC #
INSURED
INSURER A: Scottsdale Insurance Compnay
41297
INSURER B:
Bubblemania and Company Inc.
12601 Matteson Ave Apt, 7
INSURER C:
Los Angeles, CA 90066
INSURER D:
... ................. ......_._.
INSURER E:
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
:ADO L�..
JNSR
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
DATE MMIDDIYY
POLICY EXPIRATION
DATE MMIDD/Y
LIMITS
A
®
GENERAL LIABILITY
CPS 3 320659
12/01 /2021
12/01 /2022
EACH OCCURENCE
$1,000,000
DAMAGE TO RENTED
PREMISES Ea occurrence)
'.. $IOO,000
® COMMERICAL GENERAL LIABILITY
CLAIMS MADE ® OCCUR
❑❑
MED EXP (Any one person)
$5,000
�-
❑
PERSONAL & ADV INJURY
$O
................
"""'�""'°
GENERAL AGGREGATE
$2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS COMP/OP ASS
s 2,000,000
® POLICY ❑ PROJECT ❑ LOC
�
❑
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
$
❑ ANY AUTO
(Each Occurrence)
BODILY INJURY
❑ ALL OWNED AUTOS
❑ SCHEDULED AUTOS
(Per person)
$
BODILY INJURY
❑ HIRED AUTOS
❑ NON -OWNED AUTOS
(Per accident)
$
PROPERTY DAMAGE
$
❑ �, ,,,,_
(Per accident)
❑
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT
$
OTHER THAN EA ACC
$
ANY AUTO
AUTO ONLY: AGG
$
❑
EXCESS/UMBRELLA LIABILITY
EACH OCCURRENCE
$
AGGREGATE
$
❑ OCCUR ❑ CLAIMS MADE
$
❑ DEDUCTIBLE
❑ RETENTION $
WORKERS ION AND
TH-
❑ ORY LIMITS ❑ WC STATU- OER
❑
EMPLOY RS' LIABILITY
E.L. EACH ACCIDENT
_
$
ANY PROPRIETOR/PARTNER/EXECU-
TIVE OFFICER/MEMBER EXCLUDED?
If yes, describe under
E.L. DISEASE - EA EMPLOYEE
"
$
SPECIAL PROVISIONS below
E.L. DISEASE -POLICY LIMIT
$
❑
OTHER
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
Additional Insured: City of El Segundo Recreation and Parks Department
CERTIFICATE HOLDER L;ANt:tLLA I IUN
City of El Segundo
Recreation and Parks Department
401 Sheldon Street
E1 Segundo, CA 90245
ecnRn 9s onnum
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE INSURER AFFORDING COVERAGE WILL ENDEAVOR TO
MAIL.10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT
FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE
INSURER, ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE'
Alberto O Ocon
1@1
TION 1988
POLICY NUMBER: CPS3320659
COMMERCIAL GENERAL LIABILITY
CG 20 26 07 04
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - DESIGNATED
PERSON OR ORGANIZATION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Persons Or Organization(s)
City of El Segundo Recreation and Parks Department
Information required to -complete this Schedule, if not shown above, will be shown in the Declarations.
Section II — Who Is An Insured is amended to in-
clude as an additional insured the person(s) or or-
ganization(s) shown in the Schedule, but only with
respect to liability for "bodily injury", "property dam-
age" or "personal and advertising injury" caused, in
whole or in part, by your acts or omissions or the acts
or omissions of those acting on your behalf:
A. In the performance of your ongoing operations; or
B. In connection with your premises owned by or
rented to you.
CG 20 26 07 04 0 ISO Properties, Inc., 2004 Page 1 of 1 13
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this
certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
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).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contact between the issuing
insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively
amend, extend or alter the coverage afforded by the policies listed thereon.
25(2001/081
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 affirm under penalty of perjury under the laws of California one of the following declarations:
(_) 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 #
�✓ 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
immediately comply with those provis'' rzs or reement will automatically become void.
Signature of Applicant DaW 4/21
Print Name
Joseph fern
A reement for:
Dated:
Review