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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 ,•_,.,,AUTOS ..° HPR90ALITOS 21 W-O`VNED AUTOS 'UMBRELLA LAB OCCUR EXCESS LIA6 CLAI'!S•9.IACEY mm� '� v/OA}saR.S COh➢PENSAT9ON AND EMPLOYERS LIAINLRY rIN' AA"MB PNLwI*nviE4iR P 1,ATN"SRrtIt "Al" E CE T,p'S'CE.r rEl•eaCWr IACLUO'1.,..a NIA r..4.. ne.w owv in NNt PE SOKALaADt.N 3,R 3 GF.Y£R.AL AGGr4RGA` E 6 2,000.'DDO .. FRO0UCTS-C^_AeP.CPAGG 'l 2,000.000 ,S ANI➢WAL EAILEE "Twim S`NI 1 %�"'G� b SAGS"w'➢�S IP Wti ��waNl, r D✓OILY IWURY IPw aecx Lr S rROPERTT D,Q1AGiE S P rwaxruep .. 5 FAC H C'FURREKCE AGGREGATE $ 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 la fl "Mr tlm Ir d' Roams al ( cm 4 w800-776737 Valued Custonler Ske 2023 P-0, Box 312fr0 tamapa, ft 33631 �am�d IrrS�rl�lslw i Iwpa Fm Year . Maki' oalel I 20 CHEVROLET EXPRESS 3500 +I�lY�M�IIWY� 4 I Form A022 (10,) l 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 I Oil 1.80if-274440 or olocl ers.�r aPe sm I g /p iWl/ ////��%��/��///r,!ii%�//�iir is irr'i111L./l�/ r„�i�,%/iie I 1 Iv I �;P "THK �00,IN' YOWWRICL kI L IIW oP ITN ",�„ I 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