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PROOF OF INSURANCE (2024 - 2024) CLOSED, ,CI � CERTIFICATE OF LIABILITY INSURANCE °"0;,0;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 cerltficaae holder is an ADDITIONAL INSURES?, the pollcy(ies) must be endorsed, It SUBROGATION IS WAIVED, sub)ecl to the
terms and conditions of the policy, certain policies may require an endorsement. A statement an MIS, certificate does not confer Ifghts to the
Certificate holder In lieu of such end-oTsemenlfs).
Prcaaaueess E FLIP Prograrh Support
NAIVVeracity Insurance Solutions, LLC. PtOME rAx
26D South 2500 West, Suite 303 °00 0 (8 4} 2 E ,,_. ...__, .. , . I wNal
moOR1tlTss,I'nto@fllprogiram.com
Pleasant Grove UT 84062 INS,UAEA➢SI A7rOADINO COVE RAOR "Are s
N1,SUREA,A. Cleat AinjericanAflianoeInsutamceCO, 26632
INSURED
INSUn�E'R R'..
Karola Flores, DBA La Lemonade NIsuRER c
4466 W 13STh St A xavAEA a -
Hawthame CA 90250 1145U r,ER E
loVVEHAtUtu F,:EK IIt 1k-A.t IC. NUM'UtW HI-Vt51UN.. NUMBER:
THS IS TO CERTIFY TNIAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO Ti* INSURED NAMED ABOVE FOR THE POLCY PER*D
INDICATED NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR 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.
agars, AO.r94aNASR ' P'C141 EPp PaLaCY�P
—LT-- TYPE OP' INSURATIGE POLxv NVIASeR VrYYY�O%tl?r's"!1®"I''k. LrAi1'z __
GENERAL LIABILITY 1,DDD,t:tDD
EACH Ct;tURRENCE 5
X DAMAGE
'TS•OLE RENTED
ENTED
300,000
RD EP t„nyCLA!AS-LIADE % GGCUR
5,000
A PLE864748-F211989 081172023 0911712024 1000000
" GEWL AGGREGATE LIMITAPPLIES PER
AU T0000ILE LIAaNU➢T"r
tlN
ANY AUTO
ALL OVINED GCHEGULED
AUTOS
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AND EMPLOYERS LIAINLRY rIN'
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S
DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES IAllarh ACORD 101, Addlllonal Asrrwks Schedule. it more apace Is ngUuedl
Certificate holder had been added as addillonal insured regarding the above mentioned policy per attached
Additional Insured - Designated Person or OrganlZatiDn (CC 20 26 Ed. 04 13)
E L. EACH ACCLGENT 'I
EL DlSEA5E.EAECPLOYEE S
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
The CI of E! Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City e9 ACCORDANCE WITH THE POLICY PROVISIONS.
350 Main St.
EJ Segundo, CA 90245
gUTHOAl2E0 REPRESENTATIVE
©1988•201,$ ACORD CORPORATION, All dahts reserved.
ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
INS025 sol<ulI
PLE864748-F211989
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED — DESIGNATED PERSON OR ORGANIZATION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
Schedule
Name of Additional Insured Person(s) or Organization(s):
The City of El Segundo
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
CG 20 26 (Ed. 04 13)
A. SECTION II -WHO IS AN INSURED is amended to include as an Additional Insured the person(s) or
organization(s) shown in the Schedule, but only with respect to liability for "bodily injury," "property damage" or
"personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of
those acting an your behalf;
1. in the performance of your ongoing operations; or
2. in connection with your premises owned by or rented to you.
However:
1, the insurance afforded to such additional insured only applies to the extent permitted by law; and
2. if coverage provided to the Additional Insured is required by a contract or agreement, the insurance afforded to
such additional insured will not be broader than that which you are required by the contract or agreement to
provide for such additional insured.
B. With respect to the insurance afforded to these Additional Insureds, the following is added to SECTION III —
LIMITS OF INSURANCE:
If coverage provided to the Additional Insured is required by a contract or agreement, the most we will pay on
behalf of the Additional Insured is the amount of insurance:
1. required by the contract or agreement; or
2. available under the applicable Limits of Insurance shown in the Declarations;
whichever is less.
This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations.
Copyright, ISO Properties, Inc., 2012
CG 20 26 (Ed. 04/13) PRO Page 1 of 1
w y /fit+ IABIILITY
INSURANCE
Glct_,>i:Ltrtruca,v
PROGRAM
nr50i6VICE eneaP
Flipa6tgra9ru.t'Arnp
hyte'l 844-520.6992
Great American Alliance Insurance Company
Powered by Veracity Insurance
301 E. Fourth Street, 25 S
Solutions, LLC
Cincinnati, OH 452024201
COMMERCIAL GENERAL LIABILITY COVERAGE PART - OCCURRENCE FORM
CERTIFICATE PAGE
IT IS AGREED THAT THIS CERTIFICATE IS ISSUED TO THE CERTIFICATE HOLDER LISTED BELOW TO CERTIFY COVERAGE
UNDER THE COMMERCIAL GENERAL LIABILITY INSURANCE MASTER POLICY LISTED BELOW.
INSURANCE COMPANY: GREAT AMERICAN ALLIANCE INSURANCE COMPANY POLICY NUMBER:
NAMED INSURED: HOSPITALITY 8 ENTERTAINMENT TRADE ALLIANCE PLE864748
CERTIFICATE HOLDER: Karola Flores, DBA La Lemonade CERTIFICATE NUMBER:
ADDRESS: 4466 W 135Th St A, Hawthorne, California 90250 F211989
POLICY PERIOD: 0811712023 to 08/17/2024 12.01 AM. standard Time ar the Address or Thhe Cert iiare Ma1der
LIMITS OF INSURANCE
General Aggregate Limit (Other than Products -Completed Operations) $ 2.000,000
Products -Completed Operations Aggregate Limit $ 2,000,000
Personal and Advertising Injury Limit $ 1.000,000
General Each Occurrence Limit $ 1.000,000
Damage to Premises Rented to You Limit $ 300,000 Any One Premises
Medical Expense Limit $ 5,000 Any One Person
Professional Coverage Extension $ Not Purchased Each Claim
$ Not Purchased Aggregate
Professional Coverage Deductible $ Not Purchased Each Claim
Liability Deductible None
FORM OF BUSINESS: Sole Proprietor/Individual
PREMIUM: $ 169
BHTA Fee: $ 164.95
TOTAL ANNUAL COST: $ 333.95 (The cost is 100% earned/non refundable)
CODE NUMBER: 11168 PREMIUM BASIS: Gross Sales EXPOSURE: Up to $50,000
BUSINESS DESCRIPTION. Vendor, Distributor, or Manufacturer of food products; Catering, Concessions,Farmers Markel
Vendor,Private / Personal Chef,Home-Based Baker,Food Trailer
THIS INSURANCE IS SUBJECT TO ALL THE TERMS AND CONDITIONS, INCLUDING APPLICABLE ENDORSEMENTS, OF HE
COMMERCIAL GENERAL LIABILITY INSURANCE MASTER POLICY. A COPY OF HE COMMERCIAL GENERAL LIABILITY
INSURANCE MASTER POLICY ACCOMPANIES THIS CERTIFICATE. ADDITIONAL COPIES WILL BE PROVIDED TO HE
CERTIFICATE HOLDER. PLEASE READ THE POLICY AND ALL ENDORSEMENTS.
NO ADMISSION OF LIABILITY MAY BE MADE EITHER VERBALLY OR IN WRITING
FULTOEVTEARILACfI INSURANCE SOLUTIONS, LF ANY INCIDENT SHOULD BE SLC 260 OU HENT T 500 WEST ELY BY EMAIL
UITE 03,PLEASANTI R iaES. OU BY LETTER
.
FORMS AND ENDORSEMENTS applicable to all Coverage Parts and made part of this Policy at time of issue are listed on
the attached Forms and Endorsements Schedule IL 88 01 (11185).
ADMINISTRATED BY,
Veracity Insurance Solutions, LLC
280 South 2500 West Suite 303
Pleasant Grove Utah 94062
888-568-0548
ADMINISTRATOR'S SIGNATURE:
7/3/24, 2:47 PM Mail - Palmer, Linnea - Outlook
jol i"Ial+IsIng Progressive.
RIfTI , N W TIo erlegT INSURANCE IDENTIFICATION CARD . California
1 E Sr O NT EGRO pall �mrr� 47�%�54�3�R NAICNummber 94770
fffecave Date: 0612712024 Ex Irat�iom Da $212712,024
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Valued Custonler Ske 2023 P-0, Box 312fr0 tamapa, ft 33631
�am�d IrrS�rl�lslw i
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I 20 CHEVROLET EXPRESS 3500 +I�lY�M�IIWY�
4
I Form A022 (10,)
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ll 4 w 3emaln at tluecamm, mrl4 tr4 doorallcyr a the iranwe�,' eWor� I6456. I
l 4 finda saie kcat000, W,Ile r#uro' u6 jX640 e iw a-1,loirraals"am. I
P 1 Cell Progressive right of�yaT� I
I 10 REPORTA CLAIMr I
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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`) I have and will maintain a certificate of consent of self -insure for workers' y
compensation, issued b the Director
P
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,
(� 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 #
()(-) 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 provisions or the agreement will automatically become void.
D
Karola Flores 07/03/2024
Signature of Applicant ate
Print Name
ttarola Flores
Agreement for: La Lemonade
Dated: 110 7
Reviewed by: [ J TP
Thank you,
Karol Flores