PROOF OF INSURANCE (2024 - 2025)CERTIFICATE OF LIABILITY LI'SI CE oATE,MM,oD,YYYY,
04/09/2024
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. 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.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. 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 endorsements .
PRODUCER LOAN SEAN ERICKSON
-
SRE INSURANCE SERVICES PHONE 310 985 1234 FAX 888 881 223. .
E-MAIL FAM COM
12019 WILSHIRE BLVD. 1�7�is SEAN(�SRE..... _...._ _....,.., ...
LOS ANGELES, CA 90025 _ INSURER(S) AFFDRDING COVERAGE NAIC 0
wsURER A : SCOTTSDALE INSURANCE COMPANY .._�
41297
INSURED 1uQ1iPF0 R
SAUL GONZALEZ DBA SWIM WITH ME
CARSON, CA 90745
E;
F:
CnVC0A6CS RFRTIPWATF NIIIMRFR• RFVI;O.I:ON NIIIIURFR-
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED 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.
__ .............. _.--.._ _ ..---- _._._a
INSR TYPE OF INSU DL SUB POLICY l FF
LTR ''..... RANCE POLICY MM/D
..._..__........_ - ,,,._ .
POLICY EXP LIMITS
MhU'DO ,.
LIABILITY
(...
OCCURRENCE
RENCE
EACH
�.$..,. .,..1,0-0�0,000GENERAL
RAL
/COMCIALE IAILITY
.......CLAMS-MADE
a k�
/� OCCUR
PREMISES (Ea
MED EXP (Any one person)
100,000
$ 5,000..-
A X CPS7973854
04/15/2024
04/15/2025
I PERSONAL &ADV INJURY
$ 1,000 000
i
F GENERAL AGGREGATE
$ 2,000 000
L AGGREGATE S PER: E G N-EGATE LIMIT APPLIES �_ ,
PRODUCTS COMP/OP AGG
$ 2,000,000
+�,�^ PRO
POLICY LOC
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._._ -------- -------p
$
AUTOMOBILE LIABILITY
A
COMBINED SINGLE LIMIT
; ire acosdenll
d
0..,.
ANYAUTO
j
BODILY INJURY (Per person)
d $
.
I ALL OWNED („ „„ '� SCHEDULED CCC
,,,,,,, AUTOS AUTOS
W
BODILY
.......�............ ..
-64 (Per accident)
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$
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I
PROP6RD� i�AbIAOE
Is
HIRED AUTOS AUTOS
..q ft
616161
Y s
$
I UMBRELLA LlA6 OCCUR
OCCURRENCE
S
LIAR
EXCESS IM
CLAS-MADE
�
.EACH ..
AGGREGATE
___
DED RETENTION $
1
........ .......
_.$ _ ,,..._.. ---
$
WORKERS COMPENSATION
I
WC STATU O'TH
'P4%Y LIWENT'„I SR%.
ANYPR�CkP'RNEORFd'G"EXECtA'r1VG...
OFFICERIMEMSER EXCLUDED? Yr
N / A
1
..... ...� �.. ... ,..
I E L EACH ACCIDENT $ . ................
(ry in NH)
SE EA EMPLOYEE $
_
r
0 UIPTION OF OPERATIONS boio+r
E L. DISEASE - O
- POLICY LIMIT $
G
'.. DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required)
CERTIFICATE HOLDER NAMED AS ADDITIONAL INSURED PER FORM CG 2012 12 19
LOCATION: 2240 E. GRAND AVE., EL SEGUNDO, CA 90245
CITY OF EL SEGUNDO
3501 MAIN ST.
EL SEGUNDO, CA 90425
\.XIML,CL_ P%I IVIM
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESE TA71V'E
ACORD 25 (2010105) U 198E-201D AGURO GURPUKAI IUN. An ngnis reservea.
The ACORD name and logo are registered marks of ACORD
POLICY NUMBER: CPS7973854 COMMERCIAL
c .
CHANGESTHIS ENDORSEMENT #- • IT CAREFULLY.
ADDITIONAL INSURED I ..GOVERNMENTAL
AGENCY OR SUBDIVISION OR all'
MIY
DIVISION — PERMITS OR AUTHORIZATIONS
Ti fs went' Insurance provklod under the n0.
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
State Or dkwwnnmftl Aamov Or Subdivision Or Political Subdivision:
THE CITY OF EL SEGUNDO, ITS OFFICERS, OFFICIALS, EMPLOYEES, AGENTS
AND VOLUNTEERS.
A. Section ht — Who Is An Insured Is amended to
Indude se an additional loured any state or
g"1111 agency or wAK#vk4on or poliftl
subdivision shown in the Schedule, subject is the
following provisions:
1. This Irourence appiles only with reaped b
aporobons porlbernod by you or on your behalf
for which the state or governmental agency or
subdivI41on or political subdivision has Issued a
permit or authorization.
Howow.
s The insurance aftided to such additional
Insured only applies to the extent permitted
by Iarh, and
b. If coverage provided to the additional
kowred Is rooted by a contract or
agreement the kwoorice afliarded to such
addillordO insured will not be broader then
that which you am required by the contract
or agreement to provide for such additional
VAN
2. This Insurance don not apply to:
a. 'Both y iryury', opmpody d~ or
and ad1vorlisina IrW WWng out
of ope for the Weral
government. _ or " or
b. "Bodily injury' or Ixoporty dama0a' included
within the Voftdo-compleled oporelons
hazard'.
S. With reaped to the Insurance afteded Io
the Is to i i
Section III — Unit Of ce:
If coverage provided to this addlional kwxW Is
by a conlrad or agroomont, the most we
D pay on behalf of tho additional insured Is the
amount of Insurenow.
1. Roored by the contract or errl; or
2. Avellable under the WpIkable 11mits of
insu
whichever is Was.
This andorsoment shell not Increase the applicable
limits of Insurance.
CO 20 12 12 19 0 Insursios Sovioss Ofte, Inc." 2016 Paw 1 of 1
State Faring Stater -arm
Providing Insurance and Financial Services
PO Box 2358
Bloomington IL 61702.2358
Attached as requested are your replacement insurance identification cards. If the attached cards are not accepted
by a law enforcement agency or your Department of Motor Vehicle office, please contact your agent to receive
additional assistance.
Thank you for choosing State Farm for your insurance needs.
IMPORTANT - IDENTIFICATION CARDS
STATE FARM
SlateAm7pi CALIFORNIA� � ° nil THISCARD
FOR T BE KEFT IN THE INSU.. RED MOTOR
INSURANCE CARD r PRODUCTION UPON DEMAND.
State Farm Mutual Automobile Insurance Company
PO Box 2358 Bloomington IL 61702.2358
INSURED GONZALEZ,SAUL MUTL
VOL
POLICY NUMBER 4907980-AO5-75A EFFECTIVE
YR 2009 MAKE TOYOTA JAN 05 2024 T() JUL 05 2024
MODEL PRERUNNER VIN
78
PHEATSSN S INS AGENCY IJC 284C-A75
iIO�NON
COVERAGVID7 BY THE POLICY MEETS THE MINIMUM LIABILITY LIMITS
IF YOU HAVE AN ACCIDENT - NOTIFY THE POLICE IMMEDIATELY
1. Get mrr psi es, and plroneoxim bens of persons in vokeed and %Mv.sses.
Also get der irera arms of personas irruoty anxl icenlae plate
axombersfstyates of weld s.
2. Watt wit fatalt or diso.ass the ar dent with Miyorie, test Sate Fame oi• poke.
3. PromptN notify yair agent, log on to statefarm.com®, or Use the State Farm mobile
app to tie a clam.
rot EMERGENCY ROAD SrAVI useIle
Sm Farman a Na�onttr��reEsnru orcall
1-177-2)—SM.N� fi4l WE POIACY 0=111CN�^ I.LY. THIS FORME DOES
NOT OONS77TUTE ANY PART OF YOUR INSURANCE POLICY.
How to identify your coverage. See policy for full name and definition
A babiny 11 Lmergenc/ Road Service U U rmred Molor Vehicle
C Medical Payments L Physical Damage U1 Unirmred Motor Vehicle PD
D Conlxel-euive Rt i r' W' :u'ttaY arnl'1 royrl I:wpxea Z Loss of Eanixls
G Collision S OrnittMDutx"IxrruY,rvwxl
Loss of °i(l a
KEEP A CARD IN YOUR CAR.
THIS CARD IS INVALID IF THE POLICY FOR WHICH IT WAS ISSUED LAPSES OR IS TERMINATED.
KEEP YOUR CURRENT CARD UNTIL THE EFFECTIVE DATE OF THIS CARD.
ONE COPY OF THIS FORM SHOULD BE CARRIED IN THE VEHICLE AT ALL TIMES. THE FORM MAY BE NEEDED AS EVIDENCE OF INSURANCE IN COURT.
SUBMIT ONE CARD, OR A PHOTOCOPY OF A CARD, WITH YOUR VEHICLE REGISTRATION RENEWAL
Emergency Road Service information is located onYom irmi anoe card
- «-.. — — — — -.-. —.-- — — — — — — — — .. ..— ,.......-. — — — -..-...-. — ..--— —....-. — — — —
IMPORTANT - IDENTIFICATION CARDS
STATE FARNI
......_ ..................... StaterT� �.........
IIII CALIFORNIA F �71"IIF THIS CARD MUST BE KEPT IN THE INSURED MOTOR
INSURANCE CARD VEHICLE FOR PRODUCTION UPON DEMAN C)..
State Farm Mutual Automobile Insurance Company
PO Box 2358 Bloomington IL 61702.2358
INSURED GONZALEZ,SAUL MUTL
VOL
POLICY NUMBER 4907980-AO5-75A EFFECTIVE
YR, 2009 MAKE TOYOTA
MODEL PRERUNNER VIN IAN05
AGENTWATSON TRIGGS INS AGENCY INC 284C-A75
PFIC7NE F[310e74.1200 NAIC 25178
COVERAG . PR VII D BY THE POLICY MEETS THE MINIMUM LIABILITY LIMITS
IF YOU HAVE AN ACCIDENT - NOTIFY THE POLICE IMMEDIATELY
1. Get n"w^tnes, ens ewes, and phone iximbers of pre somas invoked and witnesses.
Also get driver icence mmnttaero of persoirs an Eyed and license plate
1ximd r sstkt s of vef Os.
2. Don't admit fault or dismiss the accident with anyone but State Farm or police.
3. RomptN not Your agent, log on to statefarm.comS, or Use the State Farm mobile
app to tie a claim.
For EMERGBICY ROAD SBIVICE use the State Fwn mobile app log on to statelamuoni, or call
M77-127-6757. EXAMINE POLICYEXCLUSIONS CAFEFULLY. THIS BORN DOES
NOT CONS7ITUTE ANY PART OF YOUR INSURANCE POLICY_
How to identify your coverage. See policy for full name and definition
A l7ibky H l[m1at cjVW;jd ir+*P U Uninaurlf4 iorVelicle
C rIN lPaynrets l WIr+,> x,ARam p U1thwmu, %klbt orVelicle PD
D Corrturcirensnde Rt Cyr remil aaxt frmn l: seise Z Loss of rwrx
G CullEaAn S D.,saalyl wanaaixrnvitanxl
KEEP A CARD IN YOUR CAR.
THIS CARD IS INVALID IF THE POLICY FOR WHICH IT WAS ISSUED LAPSES OR IS TERMINATED.
KEEP YOUR CURRENT CARD UNTIL THE EFFECTIVE DATE OF THIS CARD.
ONE COPY OF THIS FORM SHOULD BE CARRIED IN THE VEHICLE AT ALL TIMES. THE FOH M MAYBE NEEDED AS EVIDENCE OF INSURANCE IN COURT.
SUBMIT ONE CARD. OR A PHOTOCOPY OF A CARD, WITH YOUR VEHICLE REGISTRATION RENEWAL
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. CPS 7771950
(X.) 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 SRE Insurance Services
Name of Agent Sean Erickson
Policy Number Expiration Date 04/20/24
Phone # 310-985-1234
(_) I 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
immediately comply with thosprovisions or the agreement will automatically become void.
Signature of Applicant Date 3/27/24
Print Name
SaaiI��ul Gcan 6"
Agreement for:
Dated„
Reviewed by: