PROOF OF INSURANCE (2024) CLOSEDCITY OF LOS ANGELES
MATTHEW W. SZABO
CITY ADMINISTRATIVE OFFICER
KAREN BASS
MAYOR
October 2, 2023
City of El Segundo
350 Main Street,
El Segundo, CA 90245
Attention: Kristen Morell
ASSISTANT
CITY ADMINISTRATIVE OFFICERS
PATRICIA J. HUBER
MALAIKA BILLUPS
BEN CEJA
YOIANDA CHAVEZ
EDWIN GIPSON II
Re: Cabrillo Marine Aquarium Outreach Program at El Segundo Public Library located
at 111 W. Mariposa Avenue, El Segundo, CA 90245 on June 26, 2024.
Dear Kristen Morell,
This is to certify that the City of Los Angeles self -administers, defends, settles and pays
third -party claims for bodily injury, personal injury, death, and/or property damage. Protection
under this program is warranted to meet or exceed $1 million, combined single limit, per
occurrence.
Additionally, the City is permissively self -insured for Workers' Compensation under
California law.
In lieu of commercial insurance, the City agrees to indemnify and hold harmless the City
of Ell Segundo, its directors, other principals, officers and employees from loss or liability which
may arise from the acts or omissions of the City, its officers, agencies, employees, and invitees
during the City's use of your property.
This agreement, however, is conditioned upon the indemnified parties giving the City
reasonable notice of any such claim and an opportunity to provide or participate in the defense
thereof. It further excludes claims arising from the tortious conduct of the indemnified parties. This
letter is in lieu of any other indemnity agreement.
If you need any further information regarding this risk retention program, please contact
the Risk Management staff at (213) 973-RISK (7475) located at City Hall East, 200 N. Main St.,
Room 1240, Los Angeles, CA 90012.
AT.-hh:14240026
Very truly yours,
Allan Tan
Risk Manager
AN EQUAL EMPLOYMENT OPPORTUNITY EMPLOYER
200 North Maln Street, Suite 1500, Las Angeles, CA 90012-4137 cao.lacity.org (213) 473-7500
MATTHEW W. SZABO
CITY ADMINISTRATIVE OFFICER
To Whom It May Concern:
CITY OF LOS ANGELES
CALIFORNIA
KAREN BASS
MAYOR
January 9, 2023
RE: Proof of Insurance for the City of Los Angeles
ASSISTANT
CITY ADMINISTRATIVE OFFICERS
PATRICIA J. HUBER
MALAIKA BILLUPS
BEN CEJA
YOLANDA CHAVEZ
EDWIN GIPSON II
This is to certify that the City of Los Angeles self -administers, defends, settles and
pays third -party claims for bodily injury, personal injury, death and/or property damage.
Protection under this program is warranted to meet or exceed $5 million, combined single
limit, per occurrence.
Additionally, the City is permissively self -insured for Workers' Compensation under
California law. The City of Los Angeles will provide 30 days' written notice of any
modification or cancellation of the program.
If you need any further information regarding this risk retention program, please
contact the Risk Management staff at (213) 978-RISK (7475) located at City Hall East, 200
N. Main St., Room 1240, Los Angeles, CA 90012.
Very truly yours,
Victor T. arker
Director of Risk Management
AN EQUAL EMPLOYMENT OPPORTUNITY EMPLOYER
200 North Main Street, Suite 1500, Los Angeles, CA 90012-4137 cao.lacity.org (213) 473-7500
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 #
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 becom ubject to the workers' compensation provisions of Labor Code § 3700 1 must
y comply w" J the agreement will automatically become void.
immediately com I with those v ion or
Signature of Applicant Date l
Print Name
Agreement for:
Dated:
Reviewed by: