PROOF OF INSURANCE (2024 - 2024) CLOSEDCERTIFICATE OF LIABILITY INSURANCI
DATE ('MMODDNYYY)
0210812044
THIS CERTIFICATE IS ISSUED AS A MArrER 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
BEILO& THIS CERTIFICATE OF INSURANCE DOES NOT CON$TtTUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED,
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
010001IRTANT: It the certiesvatelh`ower—i"n ADDITIONAL INSURED, the poficy(les) must have ADDITIONAL INSURED provisions or hp endorsed,
If! SUBROGATIGiN Is WAIVED, subject to the terms and conditions of thie polllcy, certain pollcles may, requhe an endoiseimenl, A statement on
this cetilificato does not confer righits to the cartificate holder In Ilfti of suich endorsernent1s),
PRODUCER
Next First Irmu rance Agency, hnic PHONIF (A55) 222-5919
Pit Sin B60797
C-MAAL
Pala Alw CA 94306 Air"191,11i"J"C' r sIjpperz@nvx6
Snte Na6nnA Insiuramep Cr=anv. Inr g I 2R31
INSURED
Naiarno W
Na�wri Gol
350 Mann St
El Segundo, CA 910A45
COVERAGES CERTIFICATE NUMBER: 9070591819 REVIStON NUMBER:
THIS IS Ta CERTIFY -THAT THE USU-0, SELOW HAVE BEEN ISSUED —TO THITiN7SURED NAME)ABOVE FOR THE POUCY PERm
INDICATED. NOTWITISTANIDING ANY REQUIREMENT, TERM OR CONDITION OF ANY C'CINTRACT OR OTHER DOCUMENT WITH RESPECT To WHICH 7H11S
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, VIr INSURANCE AFFORDED RY THIS POLICIES IDE$CRISED 140REIN VS SUBJECT TO ALL THE TIERMS,
EXCLUSIONS AND CONDRIONS OF SUCH POLICES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAD CLAIMS,
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ry PC OF INVUl'"CE I'Motic LIM15
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X COMMERCIAILGENIEFtALL.IAB,Il�,ArY EACH OCCURRENCE $500,00040
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DESCRIP11014 Of OPERATIONS I LOCA71ONS /VEHICLES IACOAD 141, Addhiomal Ramvk% Sahooulo, may be alaao0ad It mare spa" Is maquiredj
The Cer oficate Hoider i$ The iCii7 of FI Nunda. . This Cerlikaw HoNdcr 4 an AddiUk)nai Insurf-d on the Generat LiabAiv pohcy 11" theAddidonM Imwed AcKofnatic Szarvs
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CERTIFICATE HOLDER CANCELLATION
The City of El Segundin LIVE CERTIFICATE
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VoIlunteers" IRE 51 SHOULD ANY OFTHC ABOVE DESCRISCO POLICIP.11 SE CANCELLED BEFORE
150 Maifl St THE EXPIRATION DATE THEREOF, N10710E WILL S:E DFLIVERED IN
Ell Sep n dlo, CA 9024S ACCORDANCE WITH THE POLICY PROVIVONS.
AIj1'HOFJZ6O RVP RESRNTA IM
ew
C 1988-2015 ACORD CORPORATION. All rIghts re Served.
ACORD 25 (2016103) Th,e,ACORD iniame and logo are registered miairks of ACORD
Your Insurance Identification taro
Nationwide Detactl your IldlentificatiOn Caril's along the pe,f,),ated fines,
Kvep this car (A in your vehide s ifor What's, encllvsedl.
Sc, Section f(>11owing iD Care
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identiftation Carld
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7204J 33340,0 Owc V. 2023 Jw 7. 2024
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2013
24 Hour Claims 1,800,421.3535
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I affin-ni under penalty of perjury under the laws of California one of the following declarations:
-rd.l.r 5 e bj the,
n WWO silion, is u id
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it inaustnal Rejamons as ptuivulel tP -F� L-
with the City of Ell Segundo.
Policy No. N)CIJL't A-A-)N F ML� — 00 2
I11 2 S SL *X La9N&ir C�de.� 3700 for the Igrforrnance
f the work for which the agreement w4h the City ofElsegundo is el. My womerS
carder and! policy number Policy Number Expiration Date
Carrier. 61 -t�4 4 'kl'- -
Name of Agent Phone # 57 -
(631 certify that, In the, performance of the work set forth in (lie a9feemeni wah the City of Ell Segundo, I will not
empliley any person in any manner so as to become Subject to the workers' compensation laws of ICallifornla, and
agree that. if I should become subject to the workers' cornPefls2fiOn provisions of Labor Code § 3700 1 must
imimedilatelycornply with those provision, orl agreement wjj� a Litornatically be come void,
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Sjgnature of Applicant
Print Name - - ---- -