PROOF OF INSURANCE (2024 - 2025) CLOSED16-' ' "' CERTIFICATE OF LIABILITY INSURANCE DATE tMMX7DlYYYY)
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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 GOES 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 pollcyfies) must be endorsed. If SUBROGATION 1S WAIVED, subject to the
terms and conditions of the policy, certain policies may require an endorsement. A statement an this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s),
PRODUCER 4llN4kAE, FLI, ProgramS'apporr
Veracity Insurance Solutions, LLC. „XN (pppjmg20 6gg2 r '
260 South 2500 West, Suite 303 IAA, fla)
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Johnny Ho, DBA M&J Crepes de France
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La Puente CA 91746
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COVERAGES CERTIFICATE NUMBER.,
REVISION NUMBER'
THIS IS TO CERTIFY THAT THE POLICIES OP msuRANCE. LISTED, BELOW' HAVE BEEN ISSI}E0 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.
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DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES IARxA ACORD 101, AddluotWI R—Its Schedule, N m m space le req.Uedl
Certificate holder had been added as additional insured regarding the above mentioned policy per attached
Additional Insured - Designated Person or Organization (CG 20 26 Ed. 04 13)
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of el Segundo recreation & park ACCORDANCE WITH THE POLICY PROVISIONS.
401 Sheldon st,
El Segundo, CA 90245
AUTHORIZED REPRESENTATIVE
019854014 ACORD CORPORATION. All rtnhts reserved,.
ACORD 25 (2014401) The ACORD name and logo are registered marks of ACORD
INS025 I:BI4a1I
PLF046122-F213065
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):
City of el Segundo recreation & park
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 on 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. 04113) PRO Page 1 of 1
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POLICY NUMBER
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2013
EFm°IE DATE
JULY 9 2024
MAKEIMODEL
FORD
AGENCWCOMPANY ISSUING CARD
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INSURED H
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LA PU E CA 91746--25.52
CN-7042/CAEP 6/13 SEE IMPORTANT NOTICE ON REVERSE SIOE
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.
(_) 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
Name of Agent
Policy Number Expiration Date
Phone #
Llyl 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.
Signature of Applicant i?V30 9Y Date -2
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Print Name w
Agreement for: er PJ e 1 hR 1 [9L
Dated: 2-
Reviewed by: