PROOF OF INSURANCE (2023) CLOSEDCITY 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:
(_) 1 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.
C_) I have and will maintain workers' compensation insurance as required by Labor Cade § 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
Name of Agent
I certify that, in the perfdrer,
employ any person in any man
agree that, if I should become
immediately comply with those I:
Signature of Appk"cant
Print Name
Policy Number Expiration Date
Phone #
the work set forth in the agreement with the City of El Segundo, I will not
5 to become subject to the workers' compensation laws of California, and
to the workers' compensation provisions of Labor Code 3700 1 must
or the agreement will automatically become void.
Date
Agreement for:I L ---Pry
Dated -
Insurance