PROOF OF INSURANCE (2024 - 2025)DATE(IAMVDD YYYY)
CERTIFICATE OF LIABILITY INSURANCE
0210612024
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HO'LOEft. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
I
IMPORTANT; If the certificate holder is an ADDITIONAL INSURED, the policy(iesl must have ADDITIONAL INSURE0 provisions or be en'domd. If
SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this
certificate does not confer rights to the certificate holder in lieu of such endorsement(sl.
Insurance Plus
Gallagher Affinity insurance Services, Inc.
8430 Enterprise Circle, Suite 200
Lakewood Ranch, FL 34202 866-791-1930
Dana A Sauchelli
El Segundo, CA 90245-3039
s's: sarasota.bsd. erations@aig.corn
INSURERS) AFFORDING COVERAGE NAIC a
HISURERA ASCOt
INSURER 8:
INSURER C:—IT...
INSURER 0:
SURER E:
Ins. # 647754 IN --
INSURER F:. _..
THIS IS TC CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NXMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS„
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, Limits 'Shown are as requested
R TYPE OF INSURANCE INSO�y N POLICY NUMBER USSM M16 LIMITS
X
COMMERCIALGENER�ALLgUABILITY
EACH OCCURRENCE
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AHC2312000026-01
2106/2024 2/06/2025
�D EXP(Any me person)
N/A
PERSONAL S ADV INJURY
1$2,OW.ow
atn, AGG€1ECATE LIMIT APPLIES PER .p
GENERALAGGREGATE
S3.t100.00Q ��
j( POLICY ❑JJEEwm—
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PRODUCTS-COWIOPAGG
$2,000,000
OTHER.
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AUTOMOBILE
LWBILfTY
COMBINED SNGLE LIhffr
(Ea
ANY AUTO
BODILY INJURY ( Per person)
OWNED '6 HEOUt EC
-BODILY INJURY (Per acctftnl)
AUTOS ONLY AUTOS
HIREDAUTOS NOW -OWNED
- - ....-
PROPERTYDAMAGE
;... ........�
-
ONLY AUTOS ONLY
[Pex 4cCldenll
UMBRELLAUAB OCCUR
EACH OCCURRENCE
EXCESS UAS CLAIMS -MADE
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AGGREGATE
-
DED
WORKERS
COMPENSATION AND
PER OTH•
I IER
EMPLOYERS'
LIA91LnY YIN
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ANY
PROPRIETOR I PARTNER I EXECUTIVE t�
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OFFICER'LIEMSER
tMandslory
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£L DISEASE-POLICYLM\MT
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OTHER Processional Liability
X
IAHC2312000026-01
�2106/2024�2/0612025
Each Occurrence
$2.000.000
Annual Aggregate
$3.000.000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remake Schedule, may ae aMached if more apace is required)
The City of El Segundo, Its officers, officials, employees, agents, and volunteers are listed as Additional Insured for the General Liability
policy.
CERTIFICATE HOLDER CANCELLATION
The City of El Segundo, Its officers, officials, employees,
agents, and volunteers
350 Main St
El Segundo, CA 90245
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF. HOTICE HALL BE DELIVERED IN ACCORDANCE VOTH THE
POLICY PROVISIONS.
AUTHORM REPRESENTATIVE
01988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
Get your digital proof of insurance & membership card on the AAA App
»>Download the app. Click AAA.com/app75
Electronic proof of Insurance may not be valid as proof in all stales, Please keep your hLvd erAall aer vsi on hand. Must be a current AAA member
and insured through AAA to use this feature. Available for Ifs one(@ and smartphones for An&, Nt Id3 ge,dato and roaming rates may amply
I M __ Intennsura eEO FINS R----------------------------
PROOF
INSURANCE
Automobile Club
{ NAIC #: 15598
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u Named Insured Policy Number: CAA157444359
Now DANA SAUCHELLI
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Effective Date: 10/07/2023 Expiration Date: 10/07/2024
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This policy provides at least the minimum amounts of liability insurance
required by the CA VEH CODE SECTION 16056 for the specified vehicles
s and named insureds. Coverage subject to policy terms and limits.
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VEHICLES ON POLICY
YEAR MAKE
2009 MAZD 3 SW S
2015 MAZD CX-5 GRAND TOURING
DRIVERS ON POLICY
SAUCHELLI, DANA
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i IF YOU HAVE AN .ACCIDENT CALL OUR 2417 AAA CLAWS HOTLINE 1-800-672-5246
% After an accident, exchange information with the other party and
I follow these 5 easy steps:
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I Step 1: Pull vehicle over to a safe place. Get the names, addresses, I
and phone numbers of all persons involved in the accident, e.g., uJ
apedestrians, witnesses, other passengers, etc. w
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wStep 2: Take photos of or write down the other person's driver's
license information and other vehicle's license plate number, 0
u including state of registration.
Step 4: Take photos of the vehicles involved, damages and
surrounding area of the accident, if it is safe to do so.
Step 5: Call our AAA Claims Hotline at 800-672-5246 to report the
loss. If necessary, we will arrange to have your vehicle towed. Our
provider's tow trucks always display the AAA emblem.
Do not admit responsibility for or discuss the circumstances of the accident
i Step 3: Take photos of or write down the other person's insurance with anyone other than the police or an authorized Auto Club claims
card information, representative„ Do not disclose your policy limits to anyone.
For questions or changes to your policy, call 1-877-422-2100, Monday through Friday from 7 a.m. to 9 p„m. or Saturday from 8 am. to 5 p.m.
L_----___„--__._._.._..,____________-----__..___,___-,_,___--...________________n___..____-.
Place a Proof of Insurance card in each vehicle insured under your policy. In
addition, we suggest that each listed driver carry a card. Under California law,
drivers and owners of a motor vehicle must be able to show proof of financial
responsibility at all times. These cards become invalid and should be destroyed on
the expiration of termination date of the policy. _
r - _ __ ________ PROOF OF INSURANCE _____- � ----_ VEHICLES ON-POLIC ____
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Interinsurance Exchange of the Automobile Club YEAR MAKE
VNACC M '15598 2009 MAZD 3 SW S
2015 MAZD CX-5 GRAND TOURING
Named Insured Policy Number: CAA157444359
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Effective Date: 10/07/2023 Expiration Date: 10/07/2024 SAUCHELLI, DANA
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This policy provides at least the minimum amounts of liability insurance
required by the CA VEH CODE SECTION 16056 for the specified vehicles
and named insureds. Coverage subject to policy terms and limits.
Call our AAA Claims
Hotline at 1-800-672-5246
VEH I.D. #
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IF YOU HAVE AN ACCIDENT CALL OUR 24/7 AAA CLAWS HOTLINE 1-600-672-5246 p
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After an accident, exchange information with the other party and
follow these 5 easy steps:
Step 1: Pull vehicle over to a safe place. Get the names, addresses,
Step 4: Take photos of the vehicles involved, damages and
and phone numbers of all persons involved in the accident, e.g., w
surrounding area of the accident, if it is safe to do so. 1
pedestrians, witnesses, other passengers, etc. w
=
Step 5: Call our AAA Claims Hotline at 800-672-5246 to report the w
Step 2: Take photos of or write down the other person's driver's Si
loss. If necessary, we will arrange to have your vehicle towed. Our
license information and other vehicle's license plate number, o
provider's tow trucks always display the AAA emblem. e
;including state of registration.
I
Do not admit responsibility for or discuss the circumstances of the accident
Step 3: Take photos of or write down the other person's insurance
with anyone other than the police or an authorized Auto Club claims r
r
card information.
representative. Do not disclose your policy limits to anyone.
For questions or changes to your policy, call 1-877-422-2100, Monday through Friday from 7 a.m. to 9 p.m. or Saturday from 8 a.m. to 5 p.m.
l-------------------------------------------------------------------------------------------------------------------
LWebP01,CAA 8165 (2121)
031124111
CITY OF EL SEGUNDO
WORKERS' COMPENSATION DECLARATION
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE
IS UNLAWFUL AND SUBJECTS And 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.
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.
(� 1 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 #
99 1 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
Signature of A ant G�.+�".,�"c� � e agreement will automatically become void.
Y PY P
immediately comply I with those provisions or t� pate ��2�-
�ana au e i
Print Name
Agreement for:
Dated:
Reviewed by: