PROOF OF INSURANCE (2024 - 2024) CLOSED7/2/24, 3:46 PM
Original kettle com COI - Palmer, Linnea - Outlook
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L _ CERTIFICATE OF LIABILITY INSURANCE 0-0/1912023
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 certificate holder Is an ADDITIONAL INSURED, the pollcy(los) must be endorsed. If SUBROGATION IS 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 ondorsement(s).
PRODUCER Kangarlou Insurance Agency Inc NAM IA"ArSI11NNLa .KAAgLOU
PHONE
1940 E. Chapman Ave., Ste C ?ta 73 °�O 38•8314
SfatPA-11 Fullerton CA 92831 ArsaR Ns +nlai11ro7a �N actual r its .cl.caarcr
t INSURERISI. AFFOROIIG COVERAGE NAIC
INSURER A... Slato Faris Gen"[ Insurance Cemean 251..S.f
INSURED VICLN I L APARICIO & MARIA ABURI 0 —.1ae e . rzi..
DBA MARIAS CATERING/ THE ORIGINIAL
KETTLE CORN
8937 STARDUST LANE, ANAHEIM, CA 92804
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IIlls IS TO CLRIIf Y I RA 1111_ POLICILS Of IVSURANCL LISILD BLLOLV IIAVL BLEN ISSUED 10 TOIL INSURLD NAVLO AUDVL 1014 1OIL 'ULIi VL HIOD
INDICATED NOT.VITHSTANDING ANY REOUIREMENT, TERM OR CONDITION OF ANY CONTTRAC- OR OTHER
DOCUMENT WITH RESPECT TO 'WHICH THIS
CLRTII ICA1L MAY BL ISSUED OR MAY PLRIAIN• f111- 94SURANCL Ar rORDED BY 71'L VOUCILS DLSCRIBLD
' ILREIN' IS SUBJLC1 10 ALL Tf IL TLRMS•
EXCLUSIONS AND CONDITIONS OF SUCH POJCIES. LWITS S•101YN MAY HAVE BEEN REDJCED BY PAID CLAIMS
I, TYPE OF INSURANCE POLICY NUMBER ' T G.,
LIMITS
A GeNE11AL LIABILITY y
= A.�-' 0=JRa-NCI- S 1 000,000
X CUr1r7ERClh!GEI.ERF !IAOI!li"
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AUTOMOBILE
LIABILITY-
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EXCESS LIAR . C,AYfS-h'AGE
CNn I I R..'•r%TIO\.S
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WORKERS COMPENSATION
1•� SIAr U• DiH•
AND EMPLOYERS' LIABILITY YIN
ANY
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OrTIC'-A%AIOLR L-,C! LCEDT ❑
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(Mandalvy In NH)
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DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Ants ACORO 101, Addldonal RamarY• Scnadulol d more .pace o nRwvd)
' Certificate holder narned as an additional insured with regard to General Liability -
Should any of tho above decrlbLd policies bu cancelled Loforo he oxplralron dale lhoroof, the Issuing company will mad 30 days wrRten notice to the corllGcale '
holder named
The City of El Segundo, Its Officers, officials, employees, SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
a ants, and volunteers THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN
g ACCORDANCE WITH THE POLICY PROVISIONS
AUTHORIZED REPRESENTATIVE
INSURANCE IDENTIFICATION CARD
THIS CARD MUST BE KEPT IN THE INSURED
VEHICLE AND PRESENTED UPON DEMAND
''. INSURANCE COMPANY AGENCYICOMPANY ISSUING CARD
Esuranhc f Property and Casualty Insurance Company Esurance Insurance Services, Inc
Our Contact Information
160 Pacific Ave.. Suite 201 P.O. Box 66D637
Customer service and claims center:
San Francisco, CA 94111 Dallas. TX 75266.0637
1-80D-ESURANCE (1-800-378-7262)
NAICp 30210
Email: support@csr,esurance.com
Web site www.esurance com
POLICY NUMBER EFFECTIVE DATE EXPIRATION DATE
It yvu got onto an rr"Wenl.
PACA-DO2669673 April 23, 2024 October 23. 2024
Seek medical assistance if necessary,
YEAR MAKEIMODEL VEHICLE IDENTIFICATION. NU MI'
Report the accldW to t1a;'x'fte.
2015 Chevrolet-SILVERADO 1500 LT
Do noth t discuss e atact inl with anyone except the police Do not admit feull.
Contact an Esurance Claims representative as soon as possible to report the accident
INSURED NAME AND ADDRESS ADDITIONAL LISTED DRIVER(S)
1-800-ESURANCE (1-800-37&7262).
Write down the names. addresses, license numbers. vehicle descriptions, number
JOSE G NAVARRO MAGDA A NAVARRO
of passengers. and insurance Information of everyone Invo ved in the accident.
2205 DEL AMO BLVD
Write dawn the names. addresses, and phone numbers of witnesses.
TORRANCE. CA 90501
Take photos of the accident area and vehicle damage if you happen to have a
C^,anlaara wdh Woes.
Esuronce policyholiMn con renew their vehicle m9letration onllno wil h the CA DMVI Soo your rant DMV
Do not %uget any documents except those provided by Esurance or law
renewal notice or vlalf w i1mv.—Ii for more Infomhotion
enlome"lontauawunbes
The policy meets the re0uimmenls of Section 16056 of the Colllomia Vehicle Cod..
IDENTIFICATION CARD
INSURANCE. COMPANY AGENCY/COMPANY ISSUING CARD
Esurance Property and Casualty Insurance Company Esurance Insurance Services. Inc.
160 Pacific Ave, Suite 201 P.O. Box 660637
San Francisco, CA 94Ill Dallas. TX 7526&0637
NAIC# 30210
POLICY NUMBER EFFECTIVE DATE EXPIRATION DATE
PACA-D02669673 Apn1 23. 2024 October 23, 2024
YEAR MAKEIMODEL VEHICLE IDENTIFICATION NUMBER
2016 Ford -EXPLORER LIMITED '3
INSURED NAME AND ADDRESS ADOM014AL LISTED DRIVER(S)
JOSE G NAVARRO MAGDA A NAVARRO
2205 DEL AMO BLVD
TORRANCE. CA 90501
Eaurence Wlcyholdm can wow their vehicle re6letrotion online with the CA DWI see your nut DMV
00a0w.0.0b" er vacs wrw,amwxe0ov.?aw maex Wairrvitan.
The policy mots the re0uiremenb of Section 1606 of the California Vehicle Cod.,
THIS CARD MUST BE KEPT IN THE INSURED
VEHICLE AND PRESENTED UPON DEMAND
Our Contact. information
Customer service and claims center.
1-800-ESURANCE (14W-378-7262)
Email: support�csr.esurence..com
Web site: www.esurance com
it you go&aitn an atk',rtdlent
Seek medical assistance if necessary..
Report the accident to the odice.
Do not discuss the acod a mh anyone except the police. Do not admit fault
Contact an Esurance Claims representable as soon as possible to report the accident
1$04ESURANCE (1-00-378-7262).
IM 40 ern the nae•µs, addre UAL". Iicenso 01unlber%, vand410 00r6copuoo5. num oer
of passengers, and insurance information of everyone Invo wed in the ati-, dent,.
Write down the names. addresses. and phone numbers of witnesses..
Take photos of the accident area and vehicle damage if you happen to have a
camera with you.
Do not sign any documents except those provided by Esurance or law
enforcement authorities
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 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.
Signature of Applicant ' ' Date "R"d
Print Name Maoda navarro 7/
Agreement for: _ 'V. - t "�
Dated: t'0Pf
Reviewed by: