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PROOF OF INSURANCE (2024 - 2025)CERTIFICATEOF I NU INSURANCE:05/1 W24 THffVV1TBF1LiiiTMMMr-Tff CERTIFICA7,12 DOES NOT A FIFNMMfATIVELY 4R NUGATIVELYAMEND,'EXTENOOR AL712RN THE COVRRM9 AFFORDED BY T.(POLICIES BELOW.' THIS CERTIPICATE OF INS IMtANCE DOES KW ONE TITLFTE, COOT ' T]gP-""IWEEK,T"'f~I 19911002 INSIV OA(S), AMU D IMA NET "TI(V OR P'fN.00LICHR AND Tl1E CUR7111111CATO HOLDER. I It t1woorttl1amla ftaMer . &era AD151TI15NAL IRICIRD„ a ,p a C � Mustaavra' pran na1 arr o arnn o aan . If SUBROGATION 181I'kN1�,IVED. oubjeaN to INta Ilarr�rmu algal aarrdd9orm aN wha pal y.,taabin ptall'o30® mmyp iralqufrw as a alaroa�anaat A stabomen4 an Hilra, arfIfIcAlm dons not,ac nMrrN ta to tha oarfifiloole Inolltforin ll`au DfaaruNw.aalalAoraromlrwwa' an r+nODUCEII CQQNWAGT NANSI 11has 1Varohmnd9jrt t.fndaa awlrllm K&K M suwwoa ,Group, Nmm OU114 1 4317 26D.4�59.C602 1712 MognutruzWay Pad Wmylma„ IN 40004• hTrrNreC : aal � 11 1w and rxTursrHa� :llra I IfStBIIHERMJUPr+r?i OINO b da a hlltlC II1rIIailEErl��„arauaan�aa.rac f�IIIl�I11aI Ntanlfdl IVa^.1Ir�I �e�a1 ! it a r4�a' SMAX Erhart inniaml IIVEUHEft ez t1�LaAEII Ck A :Rd'e4ar of die- ;!�Paaft, WourfiL & EhrleftninapA RPG iI1�iLUiEIt [de 1114dU.nePo e: IIIUIll9rt P: �a�r<��m �marnrraorr+ar�©�aunrrrarara, val.mhd�trara+n I�fI4aI'RIN`aIJI�JIIMiIr1R", 1is' '"M iwri Fy THAT THE P'OLI CIM OF IMUR,NINCE R fSTL'D BELOW HAVE iSEEiN'15EUSa 70 THE Di ' o r.,AMEO A9rXE FOR THE P l-ICy PERIO1La IM, )=MDR. INC,m r ANY REQUIREMENT, TEiM CM CONDITION UP ANY CONTRACT' DR OTHER DrMUMEFIT WITH RESPECI TO YdgraH THM CEIR rtPIW, 5 MAY 0E ISSUED OR WAY PERT.a K THE INSURAK4E AFFORDED FJ.'n" T1Hi' Pt:a"t,WAS GE51o=RIEV13 HEREIN IS 5LIM1CyCT TO ALL THE TEIa9I1.5} EXCLUEON19 AND CaO DITIOft OF SUCH FOLICIM LIMITS SHO11aTi MAY HAVE 1389M REDUCED INY PA IO CLAIMS. AWL `�, TYPE�•LtiIrFARDHs0,em IROD 1� qUfIRF­.. RCaUCYNU11tEiEIL LI1I �1kJac1'aaYk'r"a IIWfE9• A i X dl' mmene4L d ueitA'L LNP nu.r " 00RP " ' fl 0 05/18/24 05/18/25 E4"4I (M IA&qGMJDE WE B rYt5glrl 253 RNELIT 2.01AIMI � '"�iP �1,f7SClA � ' ' M�wf1,I, ,tfi rAEG ENP' G'ar�y rrao-p�,otN i E'xa�'�1deNI PFA"Afta Avg IF1 .My �I11de�d' dENERAriAel;<JREGArd ,l}OLa,�lCl� ' ErN'L TEIAWrr'A INPEIt CT&—C11i443MJI^J4ti�J 1',p IJ1If10' ptxl;y j Lo,C F"12321f tMIJITY tSR: Lem LWWTOPYti$TICLvvir''s, w ;alaar�wwEaJa:1�^� wrY dr�rl WDILY IRJ61fi'r' lftp wm /rut NAU tYIdsIT4 eGwlCi�mEr� Elan IIYI#N1a tlrlur i SLY ,nJ,CI'SS I HAUFQS,<%Ky _AUTOS Ka A N OTF'M10ED WILE IH 414 MII IltYLIfiiaai CJCaCadrk EA014ULMEMM EHELN.691.11a4H• r#"S.AtA is ,+,dll( HEMATE u DELI kJE lIdi7bl e 4 Ni(Nr}1i�:C�S9b H 1ti1NANN ���a STATUTE OTHER EytNLOVEM I' ° ANY17 iN FULF IiGn,"I P}1MdLf9 W K ELD"Ai31:fEIF n SE IWE a7FFICSUSIREER EF1MUDEW WffldaH yln HI-4 IL_j SIL9E9W—EAE1YROVEE EJLU�mC> F tir'L�IIIIG wym tltsvfw LffkW ESMFrIDN A. mI IIw'AiwF ,MliiEiwa aIL 4 ,rmum iwJ II" 69f$pG000X0?W400 , 05118/25 PW11F W VELti'M 1205/18/24 FN BUr 1201 AFJ =Exmg ME6a",.AL INYtf��l �I dpl�' 'Ii�Fa�1U]CJsTIttNtS r1lEIIICUL�� �4CO1r610d, J�llaaveul rS'aui�tr� 18 Its IiuT'be dll�nd H'merr�p�ee lwn�krJj Type a,1!° ratip?. DAWs, WEN111:ir , aln1pre or vocaallaim, N tiro -lour na bands. Qtrlbi a,'If161ddkio, gars p�, M1 slo Gsnla: Cam. 0I00B. Pk`iNNI'll lock; Tam of '"Nlrlwrla: J�Ir�II1rJr'IErfile, N�INq�TMa1EIlatr, f�t�llrf�a/H^ aa'HUIa9 The city of El Segundo, it's officers, officials, employees, agents, A E L I Mfl J�C1M3RCihICR'n'NlTM•I TH19 p and volunteers ,✓40141 0 15ItME&WA,Trn 18E DMLIVERLE? IN � fA o krr.'�.aaulo�� 0 'A IMLWWM The lrau r Mbar tha purchasing gaup rwj nuL9ba sub.�—,A 10 all ttta bsurarm tamni and rggldkilkria, of ft SLnla of "Tw= AGORD 28 t2H9IL(D 0 �I989,T0'iH.J4C GORPORATMN. All nq'hlg� nararrind- 'Tho a>1G'ORD mama ar>>d Ie90 sro uxigf®lurmd marnk®aYN4DORO 06/12/24 For Roadside Assistance: 800-531-8555 Report a claim, get coverage and deductible information, request a tow from the accident scene, schedule an appraisal or reserve a rental car using: usaacom, a USAA's Mobile App, or By calling 210-531-USAA (8722), our mobile phone shortcut number #8722 or 800-531-USAA. Automobile Insurance Identification Card This identification card is evidence of liability insurance for your vehicle. The card is valid only as long as liability insurance remains in force. You may be required to produce your identification card at vehicle registration or inspection, when applying for a driver's license, following an accident or upon a law enforcement officer's request Keep a copy of the ID card in your vehicle at all times. For your convenience, additional copies are available on usaacom. FNV 1 Rev. 08-16 50804-0816_01 ON9800 Fredericksburg Road San Antonio, Texas 7828E USjW NEVADA EVIDENCE OF MOTOR VEHICLE LIABILITY INSURANCE COVERAGE MEETS REOUIREM,ENTS OF NRS 485.185. THIS EVIDENCE OF INSURANCE HAS BEEN APPROVED BY THE NEVADA COMMISSIONER OF INSURANCE. THIS EVIDENCE OF INSURANCE MUST BE CARRIED IN THE INSURED MOTOR VEHICLE FOR PRODUCTION ON DEMAND. Name Policy Number 03965 23 78C 7101 9 JESSICA SIMMONS Effective Date 03/16/24 CHRISTOPHER ALLEN SIMMONS Expiration Date 09/16/24 46 VICOLO DELLA LUNA Year Make HENDERSON NV 89011-0112 2022 PORSCHE yjWR! Igt!!t fication Number USAA CASUALTY INSURANCE COMPANY 25968 CONTACT US: 210-531-USAA(8722) OR 800-531-USAA Additional copies available at usaa.com 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: L_) 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 # certify that, in the performance of the work set forth in the agreement with the City of El Segundo, I will not `err loy 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 thos pr `si is or the agreement will automatically become void. g of Applicant Date sisiiza Si Print Name JESSICASIMNION FORSMAxENTEKIAdNCVrENT Agreement for: Dated: Reviewed by: