PROOF OF INSURANCE (2024 - 2025) CLOSEDCERTIFICATE OF LIABILITY INSURANCE MULTI DATE 09/01/2023
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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 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(les) must be endorsed, If SUBROGATION IS WAIVED„ 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
PRODUCER _mq,J lJ T q —....
SHAH INSURANCE SERVICES, INC. PHONE a 323 830 0 60 V FAX N
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801 PARKCENTER DR. #101Z .. FFfG31;,iROh19.731I4.,II Kpp „r," A,I.
SANTA ANA CA 92705 NsuRER{SI AFFORDING rOVERAGE NAIL p
SELMO CALDERON COMPANY �2m 743
PHONE (800,
457 2231 / IJ�^�USANC 9ki99�ILI,AGDO% INsuRERA MAXUM INDEMNITY
INSURED FREDDY AN INSURER B-
SHAHINIAN RPG.INC/ FARMERS MARKETS VENDORS 1NSIEFF
1141 WEST 61ST STREET
IMSA qER D
LOS ANGELES, CA 90044 INSURER F: CA/2023
COVERAGES CERTIFICATE NUMBEW 271451 REVISION NUMBER:
THIS I$ TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLJOY 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,
T I TYPE OF INSURANCE.....,.,.L°5°Yfi" ..... �.... POLICY NUMBER ..�.— .HI�.MI �PT,Y ... ................... .,.....
FIICLU38E1NS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN LunlTs
— ER Y M .... ... ,.. MAY HAVE BEEN REDUCED Y A S,
INSR -- DDL LPBR POLICY FF POI, ICY EXP
/� GENERAL X BDG 0080703 08 917/23 9/7/24 EACH OCCURRENCE S 1 000 000
.—.. ERA X COMMERCIAL OIwN pp
CI A1hPo5 r Dt ' X� V rcrum� 12:01 AM 12:01 AM PR sEs a DENTED250,000
I
5.000
m��. a ` PERSONAL d ADV a onl NJURY $ ..,. —
MED EXP one ��
1 GEN L AGGfJC *Aim LIMIT APPLIES
-... , m ...... PRO- PER: PRODUCTS AGGREGATE
OP AGG 5(,%OD OQD,.,,,..
X POLICY -1 JECT LOC .. ......
®, , . e PREMIUM .. a,.w,, ...�. �. ..._ ....... f $
OTHICR ....,.., S, .......
n .... t MDIN D s'IN LIM11
AUTOMOBILE LIABILITY y, •r nc as rnPop
ANY AUTO NONREFUNDABLE BODILY INJURY (Per person) Smmm—
ALLOWNED SCHEDULED BODILY INJURY (Per S
_�„u ...........,
AUTOS AUTOS NON -TRANSFERABLE �..
HIRED AUTOS y.. AUTOS I� S
NON -OWNED � PeYt ac��'PaOngl.
.. —.
UMBRELLA LIAR OCCUR EACH OCCURRENCE S
.... EXCESS LIAB CLAIMS MADE AGGREGATE S „mm_
........- DED RETENTION $ ,.........._._....., .............�i ,,®..... 5...
WORKERS COMPENSATION— H.
AND EMPLOYERS' LIABILITY YIN
ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ NIA E,L EACH ACCIDENT _ 3
c QFa IC tRryErMNH' EXCLUDED? EL- DISEASE • EA EMPLOYEE $
f s W L.lto under E L DISEASE POLICY LIMIT S
� s sauPTi af0�_9PIFRArlGM . 18435-PUPUSm. .....................
1 AS
ES&UPTION OF OPERATIONS I LOCATIONS I VEHICLES IACORD 101, Additional Ram&+A Schedule may be ..............�---.....
D
_ ........_.
attached N moro apacee In required)
LOCATION: EL SEGUNDO FARMERS MARKET, 400 BLOCK., EL SEGUNDO, CALIFORNIA, 90245
THE CITY OF EL SEGUNDO, ITS OFFIERS, OFFICIALS, EMPLOYEES, AGENTS AND CERTIFIED VOLUNTEERS AND THE CERTIFICATE
HOLDER ARE NAMED AS ADDITIONAL INSURED.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
EL SEGUNDO FARMERS MARKET THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
C/O VAL PATTERSON ACCORDANCE WITH THE POLICY PROVISIONS.
339 SHELDON STREET
EL SEGUNDO, CA 90245 AUTHORIZED REPRESENTATIVE
w .ryrg
ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
Expiration I:
rrr r
. �
lorales
:RMONT AVE
=LES, CA 90044-3719
INSURED MOTOR
IN DEMAND.
50461 IDCO2
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 wilt maintain a certificate of consent of self -Insure for workers' compensation, issued by the Director
o 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. DG 0 0y0 03 0
Policy No_
J) I have and will maintain workers' compensation insurance as required by Labor Code § 3700 for the performance
o the work for which the agreement with the City of El Segundo is executed. My workers' compensation insurance
' are: Q
Carrier y �olicy Number Expiration Dale ✓-7 —2
carrier an Ire number
Name of� nI Phone #
A) I certify that, in the performance of the work set forth in the agreement with the City of El Segundo. I will not
e ploy any person in any manner so as to ecome subject to the workers' compensation laws of California, and
agree that, if 1 should become subject to 0 kers` compensation provisions of Labor Code § 3700 I must
immediately comply with those proviso a agreement will automa icatly become void,1
Signature of Applicant Date ��
riPrint Name 3
a Lcie ron 2024
Agreement for: cAwwn
Dated: I 4
Reviewed by: Gi