PROOF OF INSURANCE (2024 - 2025) CLOSEDAcc � WTEIMMDDIYYYYI
CERTIFICATE OF LIABILITY INSURANCE osrz6,zoza
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. It SUBROGATION IS WAIVED, subject to the
terms and conditions of the policy, certain policies may require an endorsement. A statement on this certHfcate does not confer rights to the
certificate holder in lieu of Such andorsement(s)„
PRODUCER FLIP Program SupPWI
Veracity Insurance Solutions, LLC. pMOHe (844t520 6992 GwN�7q..
260 South 2500 West, Suite 303 if ..s. 6nfolf fGiprogram.c0�m
Pleasant Grove UT 84062 YrorSURERts ArFORtINITOCOVF _ NAIC r
cD i' 2685 .. ..,...Great �rlarenCFln A�rjsnca Inauran _ .
MURED ITN uReRu.
Koji Hashimoto, OBA Twist potato oa GURER C
1275 W. Capitol Dr. Unit 114 aaAUREAD;,
San Pedro CA 90732
lMsunEa le ,
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOU
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,
GENERALITY
_X COMWRCIALGENEPAL,LIABILITY 0.''''''
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GENL AGGREGATE LIMIT APPLIES PER
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AUTDNOBLLE LUIBILITY
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EACH OCCURRENCE 'S
DAMAGE TO RENTED
3OOA00;.
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..PREMISES (Eeornax Fl... ... . .
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MED FXP IA!IY oI»pnwn) S
5,000.
PLE864746-F211942 (IS1012023 08110/2024 PERSONAL AADVINJURY s
1.000.000
GEaaERAL AGG!FEOATE
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2.000.000
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2,000,000
ANIMAL AlLEE S
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DESCRIPTION OF OPERATIONS r LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Sekeddle, a mom spaec Is r dred)
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)
CERTIFICATE HOLDER CANCELLATION
E.L EACHACOIDENT S
El DISEASE -EA EMPLOYEE S
E.L. DISEASE -POLICY LIMIT 5
SHOULD ANY Of THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of El Segundo
ACCORDANCE WITH THE POLICY PROVISIONS.
314-348 Main st
El Segundo, CA 90245
AUTNORIZFD REPREsENTATYVE
wa:Poa-AWW4 MtiVn�u +.w+nr•+annnlw.ca. nru lryrxuY ,a•:ac.,xu.u,
ACORD 25 (20141011) The ACORD name and logo are registered marks of ACORD
INS02512o1+ory
PL£864748-F211942
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
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
CG 20 26 (Ed. 0413)
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 —
LIMfTS 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. 04l13) PRO Page 1 of 1
AUTOMOBILE INSURANCE IDENTIFICATION CARD
@NAPFRE IINSURANCE'
PO BOX 8006
PLEASANTON, CA 94588
NAIC #13161
POLICY EFFECTIVE EXPIRATION
NUMBER DATE DATE
07/11/2024 07/11/2025
°NAMED -INSURED
KOJI' HASHIMOTO
VEHICLE
2006 FORD ECONOLINEE150 VAN 1 FTRE14WX6HA32252
AGENT
314 DAIWA INSURANCE MARKETING, INC.
20355 HAWTHORNE BLVD. 2NO FLOOR TORRANCE CA 90503
Coverage provided by the above referenced policy meets
the minimum liability limits prescribed by financial
responsibility law. This card must be carried in the
insured motor vehicle for production upon demand.
Sent f rorTr "Yahoo Mail " io
On Wednesday, July 3, 2024, 10:57 AM, Koji Hashimoto <I<jwest777@yahoo.com> wrote:
Hello,
Sending back the signed documents and proof of auto insurance.
Thanks
Twist Potato
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.
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,
L_) 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 #
( x ) 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 t must
immediately comply with those provisions or the agreement will automatically become void.
Signature of Applicant Dale 7l03l24
Print Name Koji Hashimoto
Agreement for:
Dated:Al
7-"-f P47JV
Reviewed by: C,