PROOF OF INSURANCE (2024 - 2024) CLOSEDC>o CERTIFICATE OF LIABILITY INSURANCE °"`"'
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 policy(ies) must be endorsed. If SUBROGATION IS WANED, subject to the
terms and conditions of the policy, certain policies may require an endorsement, A statement on this certificate does not confer rights to the
certificate holder in lieu of such endursementlsl.
PRODUCER
Veracity Insurance Solutions, I.I.C.
260 South 25M West, Suite 303
Pleasant Grove UT 84062
INSURED
Sher Lee, DBA Wok and Grill BBO
3730 Collis Avenue
Los Angeles CA 90032
UVV'4m1%AA%xI:0 4:t;K1R"IA:AAIt N1UMt5EH: REVISION NUMBER;
THIS i5 TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED NOTWITHSTANDING ANY REOUIREMENT,. 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 CLA�I�MP��S.
R TYPE OF MtSURANCE AWL SUM Y ErF POLACT YYY.
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DESCRIPTION OF OPEMTIDNS I LOCATIONS I VEHICUS fAsach &CORD 101, AdO mW R—Itz SchWbiv.. d m span lA Iequaedl
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 City Of El Segundo, its Officials, employees, agents and volunteers
TION DATE THEREOF.
ACCORDANCE WITH THE POLICY PROVISIONS NOTICE WILL BE DELIVERED IN300
Main Street
El Segundo, CA 90245
AUT14DR20 REPRESENTATIVE
19110W2014 ACORD CORPORATION. All rights resaTYed.
ACORD 25 (2014101) The ACORD name and logo
are registered marks of ACORD
ONS02512amou
PLF046122-F211689
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, its officials, employees, agents and volunteers
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
CG 20 26 (Ed. 04 13)
A. SECTION tt - 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 contractor 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
lccY.
iA Scan the QR fa 1 kier _ _
Portal or mobile app. You can doWnlo r digital
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Auto Insurance Identification Card(s)
.State taw requires that You be able to provideproof of insurance. You can use the card(s) below
to show that you are in compliance with stake (aW.MERC,
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CALIFORNIA EVIDENCE OF LIABILITY INSURANCE,
POUCY,NUMBER: CAAPo000129470
EFFE
QIVE DATE:O1/21/2024 EXPIRATION`DATE: 07/21f20Z4y
„.
Po"pariy NAICf 27553
O- a�-to -1 A,'CA 92711 73o
NAMED INSURED:FDDI°I°IDNAL DRIVER s . �v SHAR Y LEE I
220 EL VADO RD
\ DIAMOND BAR, CA 91765-1611 It
Y AR , _ MAKE MODEL
\;; CHENROLEP\ \\ VIN
EXPRESS -
TO REPORT A CLAIM, 24 i OUR$ A DAY, 7 DAYS A WEEK, PLEASE CALL 800503-3724
For access to ROADSIDE ASSISTANCEONLY, lease call (866) 64T8
This Insurance complies with CVC Section 16056 or 16500.5
This ��f*carded In the insured motor vehicle for jurtion upon demand. Any alteration will void this card. Any binder or policy issued
thW60WIS Void if any check, moneyorder, credit ft AOi.
� or other non -rash method of payment ls not honored when first presented.
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 eedury 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 Citv of Ell Segundo.
Poilcy No
(__J 1 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
car*ier and policy number are:
Carrier
Name of Agent
Policy Number Expiration Date
Phone #
is j 1 cer`rrfy 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 7t3L24-
Print fume Shaf Lee
Agreement for: .,.r... _w _. y
Dated:
Reviewed by _.. A