PROOF OF INSURANCE (2023 - 2024) CLOSED12,/5123, 10:51 AM
MW - Palmer, Lininea - Outlook
0 DATE (MMADONYYY)
AC"RV CERTIFICATE OF LIABILITY INSURANCE I I f2 7r2U 23
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY ANID CONIFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOK THIS CERTIFICATE OF FNSURANICE DOE$ NOT CONSTITUTE A CONTRACT BETWEEN THE IISSUlIN43 INSU:RER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the cortificate holder Is an ADDITIONAL INSURED, the pollcyfies) Ilmust have ADDITIONAL INSURED provisions or be endorsed.
0 SIUBROGA7TON IS WAIVED, subject to the terms and conditions of the polky, certain policies may require an endorsement. A statement on
this cerfificale does not confer riahts to, the certificate holder in 114ou of such endorsementis).
PRODUCER
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American Specialty Insurance & Risk Sorvices, Inc,
.PHONE FAX
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dba A,S A, R,SA. Insurance A,genry (CAI[ icenso AlOE'7?EStt
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Fort Wayne IN' 46804
INSURERA' Arch lnsur ny
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INSURED
Iwo Hamandez ilba Grupo FoJkMoco Sabor De Mexico
0490AVA C
23002 S, Voemont Avo,
INSURER 0 i
INSURER E.
Tonance CA 90502
WSUPER F
COVERAGES CERTIFICATE NUMI 110102110846
REVISION NUMBER.
THIS IS TO CER71FY TRAT THE POLICtES OF INSURANCE LISTED SELOW HAVE BEEN ISSUED 'TO rHE INSURED NAMED AEC':U4°F FOR THE POLICY PERIOD
INDICATED, NOTWO I HSTANDING ANY REQUIREMIE.Mr TFIRM Irk CONOI)110N
OF ANY CON "TRACT OR OTHER DOCUMENT WITHI RESPEc
T 'ro WHIICH THIS
CERTIFICATF MAY BE ISSUED OR MAY PERTAIN THE INSURANCE AFFORD150 BY THE POLICIES DESCRIBED HEREIN I,; SIjBJFCT TO AI-L THE TFRwS,
EXCLUSWNS AND CONDITIONS OF SUCH ROUCIES I-MAITS SHOWN MAY HAVE
BEEN REDUI BY PAID CLAIMS.,,,
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TYPE OF IINSURANCE POLWY Iarwuermuminauf
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)t,SCMVtION OP 0135RArIONS I LOCATMNIS,1 VEHICLES $ACORD 1,011, Adjdtflaarrasl ROMA'As Schodula, irrmiav be JftaChad 0 rao" SPaca Is requhred)
-Evidainc,00fcoveiraj,qewRhfl9"CttDthe ('VTYC,FIEI SEGUINID0 JOY AROUND THE WORLD on iDecernbeir 07, 2!023,
Oty al' El Sagundo Parks 8 Flocreakin and I.Axary SHOULD ANY OF TINE ABOVE DESCRIBED POUCIE3 BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE VALL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS,
401 Sheldon St,
NUTHOALcED REPRESENTATIVE
El Segundo CA 90245
V 19811-20115 ACORD CORPORATION, All rights reserved.
ACORD 25 (20116103) The ACORD name and fogo are registered marks of ACORD
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INSURANCE
A L E X L`;'k A wt*<" R I UO' N , I two<" E N E
ALVA'Kw`EZ HERNANDEZ,,
P01LICY NUMBER EFFECTIVE
195380015 06/01/2023 — 12/01/20231
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with Ole City of 8 Segundo.
of the work for whiich the agreement with the City of El Segundo is execulecL My workers" compensation insurancz
carrier and policy number are,
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rtify that, in the performance of the work set forth in the agreement with the City of El Segundo, � will not
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Revieiwed by: insurance pprovai:
aPis Manager
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