PROOF OF INSURANCE (2024 - 2024) CLOSED- - - - - ---------- ------
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CERTIFICATE OiF LIABILITY INSURANCE 0111 21 11`2�
PIRODUCm
Kaorcher losui an Alara Group Agancy,
11555 Hill mood, Driv* Suite 140
Las Vanes. NV B9134
INSURED
I m�l ai�l r Nl dcl oNRollill I dodSo Ir au,
divi'lon Vik�v A 1112�00�,
-- ....... . ....... ---- .............. . .... . THIS PS TO CERTNFY THAT THE POL lCiTES OF INWRANCE LISTED BELOW HAVE SEEN ISSUHE- ED TO TINSUNVFOR RED AFD A,50VF THE KAJCY PERADD
INDICATED. NOTWI71 fSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRAC T OR, OrlIER DWUMEN T W71,1 PIESPLCTTO WHICH THIS
CERTINCATE MAY BE ISSUED OR MAY PERTAIN, 'THE INSURANCE AFFORDED BY 7HE POL ii DESCRIBED HERIEW * WOJECT TO ALL THE'TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POUCIES OMRS SHOWN i HAVE BEEN REDUCED BY PAW CLAJMS
TYPE OF I SURR -WiEf"" WDE—VEW'"
IMM POLICY IWOMSER pufe-f "F I , Umm
JJB., — ArYp - . ............... immmir-y-yj -------
A X CONIVIEfti OENtRAL LABi fl IPK-N,rCNJ533 M F2N12; W 1201,11 LAcHCX::CURRI&?&-k
CI AAAS 4AADE, OcCalip R-6
51 x mEmis 5 " �
f A 00 0,( A)
WGREGAI 9 UIAXY APPIL�r,3 PER,'
POLKN wc
.............
.. .. ... ... ... ... ... ... ... ... ... ... ... ... ... ....... . . .......
AUTOMMUE LL"KJTY czmaINIED SMU LIAM
My AUTO 900MILYMNiURY
OWNED Mg IRTIO
AUON TOG LY AUTHS -Vopw- -
ONLY
.......... 1 . ... ................................................................ .
LWAri UAB OrCUR EACH ML.141RHENCE I4...... ........
Excfss UAN CLAM&MADE A Q,
WORXERS COMPENSWrION
AND EMPLOY"S'LlASKM Y d N
ANY Iry Er CA F, A J� 11111
rXCLUDED? T - .1 — ------ . .........
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I it r N Pwn t P111411111 C$r OPCRATI)OW bek� Pmg.ks't L wa
A ImJuvWd III
DESCRI)MON OF OPERAMONS I LOCATONG I VEHICLES PACORV sol, AdAgonaiN Ronmirks Wh4dulli my bo sUrbiod It mom opace Lo r"li
Rx Naw,.apoyllja9h',
3o[(j (fi)IJ Iuli gw, wilillo, I III,, 01'Cr&c 0111i vwllh xxcp,4jlyc, bodgrvarld Ovclk �ojfil,�d try
filo vow R)RF5
. . . . ....... . . . . ............... . ..... . . .......... . ............................. . . . . ............................. . . . ...............
SHOULD AW Of THE ABOVE DESCRIBED POLCIES BE CANCELLED BEFORE
THE EXENZATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
I, o"IG K,1,0 I C.,\ tOO8 15 ACCORDANCE "TH THE POLICY PROVISIONS,
ACOW 25 Q2016)03) 0 198 8-2015 AC01i CO"'ORATION. AJ I rights raise rved.
The ACORO, namie andl logo airs registered marks of ACORD
RUOWAAAR�I'
I affirm undler penalty of: Iperju.ury sunder the liaws of Calffbrnla one of the following declarations-,
(_ I have, and wrill maintain a certdicate of consent of self-insuire for workers' corripensation, issued by the Drector
of Industrial If ellafions as proOded for by Labor Code § 3700 for the performance of tfie work, set forth the agreement
with the City of EI Segundo.
lm�
(_) I have end will rnainta4i workers' compensation Iinsurance as required by Labor Code § 3700 for, the peft-rinance
of the work for wNch the agreernent with the City of B Segundo is executed My workers' compensation, rnsurance
carrier and pohcy number are.
Carrier Policy NU tuber Expiration Date
Name of Agient Phone #
cortify that, in the performance of the work set forth in the agreernew with the City of El Segundo, I wilf not
,employ any, person in any manne,r so as to become subject to the woilkers' compensation laws of Califorrfla, and
agiiree that, of 1 should bocome subject to the workeiis' cornpensabon provisions of Labor Code § 3700 II must
trans or �the a�greerneintwifi �automs�ticafly b�ecorrne �voidl
immediately comply mth
9/2012�023
Signature of, pplicant Date . .....
Phint Name Andrew , Hanlen.....
Agreement for,
Dated D uraince Approval
ns
Reviewed by�