PROOF OF INSURANCE (2023) CLOSEDCEOF LIABILITY I S ..CE D7 DATE(M21MIDDIYY022 2
:,� �"IF'1CA'b � 2
PRODUCER (949) 443-2733 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Ship to Shore Insurance Agency HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
24681 La Plaza, Ste 390 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Dana Point CA 92629- INSURERS AFFORDING COVERAGE NAIC #
'INSURED INSURERARLI Inurance Com 8.n
Wright, Paul INSURER B:
P.O. Box 22 INSURERC:
INSURER D:
Silverado CA 9267 6- INSURER E
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLIC
REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS C
THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLU
AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
NSR ADO"L PO CY EF'FEC"IIV LI Y T10N
LTR NSR, TYPEOFINSURANCE POLICY NUMBER DATE(M DATE(MMAND
GENERALLIABWTY J ZIX aO101505 1 07/19/2022 07/19/2023
CLAIMS MADE
LIMIT APPLIES PEN;::
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULEDAUTOS
HIRED AUTOS
NON -OWNED AUTOS
GARAGE LIABILITY
'��
6 ANY AUTO
EXCESS/UMBRELLA LIABILITY
OCCUR CLAIMS MADE
I
DEDUCTIBLE
F:ETEN'IION a
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNERMXECUTNE
OFFICERIMEMBEREXCLUDED?
If yea, describe under
SPECIAL PROVISIONS below
OTHER
DESCRIPTION OF OPERAT ONst,ocATCON -' CLESMCL,USIONS ADDED' BY ENDORBEMENTISPECUIL PROVISIONS
Additionally Insured: Ciy of Elseguado,
Recreation, Parka and Library
dept./Aquatic inflatable repair
401 Sheldon St.
E1 Segundo, CA 90245
City of El Segundo
Recreation, Parks and library Department
/ Aquatics Inflatable Repair
401 Sheldon Street
El Segundo CA 90245
ACORD 28 (2001108)
Y PERIOD INDICATED. NOTIMTHSTANDING ANY
ERTIFICATE MAY BE ISSUED OR MAY PERTAIN,
SIONS AND CONDITIONS
OF SUCH POLICIES.
LIMITS
EACH OCCURRENCE
$ 1,000,000',
DAMAGE TO RENTED
100,0001
PREMISES Ee ocnunence
$
MEDEXP.. onePereon)
$ 5,000',...,
PERSONAL&ADV INJURY
$ 1,000,000
.....
GENERAL AGGREGATE
$ 2,000,000
PRODUCTS -COMPIOPAGG
$ 1,000,000
SRLL
1,000,000
COMBINED SINGLE LIMIT
$
(Ee QWdent)
BODILY INJURY
$
(Per P—)
BODILY INJURY
'',....$
(Per accident)
''...PROPERTYDAMAGE
''.........,$
(Per accident)
'.. AUTO ONLY - EA ACCIDENT
$
OTHERTHAN EA ACC
$
$
AUTO ONLY: AGG
EACH 0 .(URRFKF
$
1 AGGREGATE
._
$
$
$
S
-�yy 0.
T LIMITS
E.L. EACH ACCIDENT
$
E.I_ DISEASE - EA EMPLOYEE $
E.L. DISEASE - POLICY LIMIT $
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
30 DAYS WRrITEN 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
AT.i INS025 (01onw ELECTRONIC LASER FORMS,
a ACORD CORPORATION 1988
4C, 00)327- iS Pegs 1 of 2
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 #
(2L) 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 th visions or the agreement will automatically become void. 11 /10/2022
Signature of Applicant Date
Print Name Paul Wright
Agreement for:
Ym 1
1
Dated: i
Reviewed by: