PROOF OF INSURANCE (2024)CT
AC310RO CERTIFICATE O�F LIABILITY INSURANCE
THIS CERT[FICATE IIS ISSUIED ASA MATTER OF INFORMATION ONLY AND CONIFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGAVVELY AMEND. EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANC E DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING IINSURER(S)i, AUTHORVED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER,
JIMPORTANT. 11 Ithe certifilcats holder is an ADDITIONAL INSIURIED, the policy(lies) must have AIDDITEONAL INSURED provisions or be endorsed,
If SUBROGATION IS WAIVED, subject In the terms and conditions of the policy, certain Policies 'MaY 1`04uire an endorsement. A statement on
this carlVicate doee; not confer rights to the certificate holder In lieu of such endorsoment(s).
PRODUCrAt IN I , fariner hoi
Jaffe Insurance Agency f 'a N wli 5050 310), 827-60011
13160 Mindanao Way #204 Tanner@jIliffeinwrance,rom
A Deli PRi 51 A,FF 0 A DINE C0VrRA4e
Marine 40 Rey
INSURED
Marty Felpn
331'2 Tilden Ave
CA 90292 N We"gors A . Hi$cox
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LOS Angielas
CA 90034 wSURSR
F :
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COVIERAI
CERTIFICATE
NUMBER: CI-24221113476
REVISION NIUMBIEk,
THIS
igrOiCEiR'riFYTHAT,rHEPOLICIES,OFINSURAN,CEL
TED BELOWHAVF BEEN ISSUED
TOTIAE TNSUREDI
NAMED ABOVE
FiCRTHE POLICY II
INDICATED,
NOTOVITHSTANDIING ANY REQUIU11i
TERM
OR CONDITION OF ANY CONTRACT
OR CITHER
DOCUIMEN7
Wi RESPECT TOWHIC" THIIS
CERTFIC,AT'E
MAYBE ISSUED OR MAY PERTAIN'„
THE
INSUIRANCEAFFORDIED
BY THE POLICIES
MSCRT8ED
HEREJN IS SUBJECT
TOALL THETERMS,
5XCI,
USIONS AND CONDITIONS OF SUCHPOUCICS.
LIMITS
SHOWN MAY HAVE, SEEN REDUCED
BY IPA fD CLAIMS.
VAN,
TYPE OF INSUI
POLWY NUMSER
ININDOW")LatnTS
X COMPTER"LGONCRALLIMAILfTY
EAtH OCCURRENCE $
CLAIMS -MADE N, OCCUR
2a, W, E.Emw �el-
5,000
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Y
F100812,301&3
11212112023
12121/2024
p0RsOwkAA0VJNJURY 5 11,0001,000
56AFIL A90RE-OATE LlIM111 APP UES FER"
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potli r�CrED LOC
PRODYUT -coMPIOPAGG S 2,000,0100
Employee Benefits 5
AU30101001LE LASIUrTY
ANY AJIi TO
M)bky pKRINY ip., poowl) IF
OWNFID SCIAEM&E0
0 ofty IN A wly ipor Aukfafli) I
AVro'S ONLY H AUTOS
HIRED NON 4WINED
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AVTOS ONLY AVOSOMY
por S"4ara�
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USAVIRELLAIi OCCUR
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EXCESS UTAO CIAIMS4WA
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DESCWITION OF OPERATIONS AOCATIGNS VVEHiCLES IAC ORO, 10I.AddiRTaival Romarki Schodu la, May W Attathad liffloto SPA Coll 00i
The City, uf 5T SegUndo, its Officer s, officials, employees, agents, and valuirtuers are included as Adolfianal Insured as respie,01 to the Operations of the
Named insured per written Convect,
The City of El Segundo
350 Main St.
M Segundo
ACORD 25 (20116103�)
SHOULD ANIY OFTHE ABOVE DESCRIBED POLICIES HE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DEILIVERED IN
AC"RDANCE WITH THE POLICY PROVIS40i
AU ll 40RIZED RtPRESIENTAFIVE
CA 90245
0 1980-2015 ACO,RD CORPORATlCIX All rights reserved.
The ACO RD In aim e and log Is af e reg istere id marks of AC ORD,
oil- 111311 INIMNOMIM
w,ith the City of El Saigundo.
Policy No. ---. . . ........... . ......
(_) i have and wilt 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;
Carfler Policy NUmber Expiration Date
Name of Agent Phone #
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 those provisto the agreement will automatically lbecome V011d.
Signature of Applicant ------ - Date
Print Niame MA V k , V,. PC. 4 '9 e"� W%.
jAgreement for -
Date d-
OEM=*
315/24, 12 � 17 AM
My-Apmu mm > Ayj Q-pglLc,y, > Vehicle coverages & details
LTMINIM
Add/replace vehicle �Rem e vehicle only
Ommam=
. . . ....... . ............ .
2019 Volkswagen Golf Sportwagen S,w
Coverages, Details
Bodilly injuiry, fiability
$100,,0001 per Person
611d't �"
Property diamaige
$100,000 per peirsoin
$300,000, per occurrence
[C,h a�n]ge
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315,24,112 � 17 AM
U'ninsuired ideduictibile waiiver
Yes
Vehicle delaOs
Giaraige ZIP code
90034
Annual mil�es
2,5011 - 3,500 mHes
Loan/lease cornplany
Volkswagen Credit(Lienholder)
0=22MM
'The prenlWm amount and inforrnabon displayed may not refiect riecent poky changes or payments, Pllease aflow up to
3 business days for your new inforr'nabon to be reflected run these records.
This ds for (nfornnationall purposes only and os riot ai cornpreh&isive definition of a[l coverages, qualificcatoons, lirnitaflons,
etc.
This 'rs riot interided to mjj0ace yout poticy docurvenis and declaraltions that are rna6ed to you Insurance 'us in effect oinly
for the cinvpraigps arid lirnfts of liability shown on the declafariom3 and as set forth in the insurance poficy Wrd
endorsoments Please consult the policy and one of our insurance agents for informatOn,
peal wr terms rndl nditions .
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