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PROOF OF INSURANCE (2024 - 2024) CLOSED1'r Nrn Y� 11-T19YIY•.r" 1.1"iMrY N.i AI STOCK COMPANY WITH HOME OFFICES INBLOOMINGTON, ILLINOIS RENEWAL DECLARATIONS gFBox 2,715 wnon, IL 61702-2915 Named Insured AT2 006842 3125M-23-1354-FA75 F N WELL, CAROL EL SEGUNDO CA 90245-2205 11111111111111111'I"!IIIII'Illllllllll'Illl'Illlllllllllll'Illll Businessowners Policy Policy Number 92-J2-0525-2 Policy Period Effective Date Ex iradon Date 12 Months SEP 1 2023 SEEP 1 2024 The polipv period begins and ends at 12:01 am standard time arule premises locauun. j Agent and Mailing Address V Eli BARNHART 502 MAIN ST EL SEGUNDO CA 90245-3069 nunLlc _ :-zin: z`2_8911 1 IIY11L Automatic Renewal - If the policy period Is shown as 12 months, this policy will be renewed automatically subjectto the premiums, rules and x,.¢., 1"..... .i tlC ewk„7«, tS..... �..�-,T., ,»+..1 11 ,.. .11 ♦1. r All ..hnenooJl ienhnlrler �:': IM�,� r1.^.tC� ;^ muI i s Its VIUCVk th11 GR k"f Dior: UT F"a'rlic p poi"IWU. I9 UMwa pevm,y is ael ilileiatzU1, +dc duiil g2va;;;u an l,l:„ .. �y..y..��� 1........ 1 compliance with the policy provisions or as required by low. Entity: Individual NOTICE: Information concerning changes in your policy language is included. Please call your agent if you have any questions. POLICY PREMIUM Minimum Premium Discounts Applied: Years in Business $ 325.00 Prepared PUN 1 2023 © Copyright, State Farm Mutual Automobile Insurance Company, 2008 CHIP- 9 20 Includes copyrighted material of Insurance Services Office, Inc., with its permission, 046011 294 1 Continued on Reverse Side of Page E 1Y Page 1 of 7 530-565 0.2 05.31 2011 I013231c ,m RENEWAL DECLARATIONS (CONTINUED) Businessowners Policy for WELL CAROL Policy Number 92.J2-052 .2 Coverage M - Medical txpenses (Any One Person) $5,000 11,94, Damage To Premises Rented To You $300,000 LIMIT OF AGGREGATE LIMITS INSURANCE Products/Completed Operations Aggregate $2,0Uo,000 ' General Aggregate $2,000,000 Each paid claim for Liability Coverage reduces the amount of insurance we provide during the applicable annual period. Please refer to Section II - Liability in the Coverage Form and any attached endorsements. Your ^'° y w J nwi:ai.a of ti:�.C.v .�eclarwt„^.nc Oho RI�ICINIGCCfl1Aln1�C7C rrlv_... __ . _.._C)PRA c_11hnwn In In __nnri anj nt hpr forms and endorsements that apply, including those shown below as well as those issued subsequent to the issuance of this policy. FOR N EN ORSEMENTS CMP-4101 Businessowners Coverage Form FE-6999.3 "Terrorism Insurance Cov Notice CMP-4260.1 Amendatory Endorsement -CA CMP-4261 Amendatory Endorsement CMP-4705.2 Loss of Income & Extra Expense CMP-4709 Money and Securiiies CMP-4860.1 Al Design Person Org FD-6007 Inland Marine Attach Dec ` New Form Attached Interest Type: Addl Insured -Section II Endorsement #: CMP48601 Loan Number: N/A THE CITY OF EL SEGUNDO, ITS OFFICERS, OFFICIALS, EMPLOYEES, AGENTS AND VOLUNTEERS 350 MAIN ST EL SEGUNDO CA 902453895 Prepared 23 Q Copyright, State Farm Mutual Automobile Insurance Company, 2008 PUN 19 9 2020 Includes copyrighted material of Insurance Services Office, Inc., with its permission. CMP 046013 294 Continued on Reverse Side of Page Page 5 of 7 t State Farm Companies 2500 Momad"at BWlevard Murireasboro, TN 37131-0001 CAROL WELL EL EGUI`'�t7O CA 90245-2205 Ed Bamhart 502 Main Street El Segundo CA 90245-3005 Phone: 310-322-8911 � A Would yvu like, :o go paperiess? � Scan OR or visit statefatm.com! -»�.. jmNoilcas w Sign tiN tuuay. ShMnL ,Yu fn�r Y— ww.m�nt Ltvr�'� vntr rMnin4 We received your payment Wth check number 3558 in the amount of $373.19 on January 29, 2024. We applied yourpayment as described below. ff you did not autholf a this transaction, or befieve you received this information in error, please contact yourState Fdrmo agent. Winn calling, please use your payment reference numberA791NW85E. PoNcy number Policy type Amount paid P360856-A29-75F $373.19 2008 TOYOTA CAMRY 4DR Total amount paid to 6118ng Account $373.13 THANK YOU FOR YOUR PAYMENT. WE APPRECIATE YOUR BUSINESS. Ns race#9 is for Me Payment towor#$ lira poraci'es andlor acco tints risled above ar4 d does nol rtrlt* d policy or account balances. The defy anNor bme on ft receipt may not be lisp same as cove c4 a elifsflve Oafs). Check Go vemp documents for coverapO affective date(s). ftta Fawn considers a payatant to are a mapted if Maets ON Wky pmWons and pa)mvnt is calecfeda If State Farm Is unable to celled payaaanl for any reason arts recelpf is wend: Yong guaranraa you tarn or Nava legs( access ld 0 a financial s'ommt youVo indicated (or this pornont and payment complies wrt4h applicable law. State Fawn array aWal'e a*sbmnfsnorany ban s debitedlueddad in aaor, overpaymants WU be appgad to your outstanding balance or added to yorrr poky as applicabia_ Policies identified an this receipt are provided by one or more State Farm affiliates. The State Farm affiliates Include the listed oadtles and any other subsidiary or aMitats hereafter farmed or acquired by state Farm Mutual Automobile Insurance Company. Please also note that a currently listed entity may also atop ofFering this agreement • State Farm Mutual Automobile Insurance Company State Farm Fire and Casualty Company • State Fans Life Insurance Company • State Fame Classic Insurance Company • State Farm General insurance Company • State Farm Life and Accident Assurance Company • Slate Faris Indemnity Company • State Farm Florida Insurance Company • State Farm Guaranty Insurance Company • State Farm County Mutual Insurance Company of Texas • Slate Fame Lloyds Please refer to your pollcv or contact your State Farm agent for more information. 10094titi ." CALIFORNIA INS NdYC. .. D •z':. .."1..R'�'«.'.�r .Y.x,Y rA .9 "x^i i.. W1Lw.,..,,W. P,...1'4 W:;,, e. .. '.'.. .:... IY �w'w '.�.f,Fff State Form Mutual Automobile Insurance Company Psi Bona 2350 Bloomington IL 61702-2358 INSOREii WELL, CAROL MUTL y0t PUUCYNUMBER P360856-A29-75F EFFECTIVE � � 0£ 0080AMAKE TOYOTA UIN JAN 29 2024 TO JUL 29 2024 NIOUNINSIMM AGENT Eta BARNHART' i354A75 PHONE J310R322�-6�911 NAIL 25178 CrG0.�iH"w'WIEik eY THEPOLICY MEETS THE MINIMUM UA9ILITY LlfldRS rwr3WEra�SGESA G13GN94%pEEHOEM, SeSIDE—f H'ANEXPLANATION, "�xurry wr . i�. A"q.3.....1..,»1....... � i Fri Nnfflv°."'.r:vv� h17 ,he ;nfnrrl af'10n Shc:Nn for r'wwq-ic"Paw NiMal 1xnowV110'A L."IVOI.l Y] " For each automobile, the Principal Driver is the individual these drivers. who most frequently drives it. aah driver is designated as an Assigned Driver on the household automobile that they most frequently drive, Your :J W 4 :See your policy for an explanation of these coverages. A Liability Bodily Injury 250,000/500,000 Property Damage 100,000 $190.57 C Medical Payments 1,000 $6,12 D Comprehensive $26A2 G 100 Deductible Collision _ $95,23 H Emergency Road Service $2.58 R1 Car Rental & Travel Expense $50 Per Day, $1,200 Max $35.96 U Uninsured Motor Vehicle Bodily Injury 30,000/60,000 $15.72 U1 Uninsured Motor Vehicle Property Damage $0.59 Amount Due $373,19 If any coverage you carry is changed to give broader you the broader protection without issuing a new policy, protectie^'.ttt;; n.^, 8dditi^vn°.l Yre niL'r^ charge, `a:e :')ill �11'g startinnn on the date %we adopt the broader protection. Multiple Line Driving Safety Record California Good Driver Loyalty Total 1Olsoounts $1,144,5 Other Available Discount(s) You may be eligible for additional discounts See the enclosed insert for more information, Mature Driver Driving Safety Record g Plan -i s a w Policy Number: P36 0856-A29-75F Prepared December 7, 2023 030149 determines what you pay for Liability, Medical Payments, Comprehensive, Collision, and Uninsured Motor Vehicle (confinA on next page) Page number 3 of 5 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. U 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 # (% l 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 Signatureimmediately Applicant mwith thole arovisions or the agreement , will automatically become void. ,,. �., .�".�,� Date Print Name '�`" �" °� 'J[— Agreement for: Dated: Reviewed by: