PROOF OF INSURANCE (2024 - 2025).....1 Policy Number. P100.087.007.3 Date Entered: 02/20/2024
11 DATE (M M/DO/YYYY)
CERTIFICATE OF LIABILITY INSURANCE
2/20/2024
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 have ADDITIONAL INSURED provisions or 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 certificate holder in lieu of such endorsement(s).
PRODUCER I CONTACT
Solomon Insurance Agency
880 Apollo Street
Suite 335
E1 Segundo, CA 90245
INSURED KNB Consulting, LLC
C/O Kristen Bergevin
1142 S Holt Ave
#3
Los Angeles, CA 90035
COVERAGES CERTIFICATE NUMBER:
(310)414-9409
(310)414-9327
4NSURERP� AFFORDING COVERAGE NAIC R
INSURERA: Hiscox Insurance Company Inc
INSURER B t
INSURER C
INSURER D :
INSURER E :
REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY 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,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
TYPE OF INSURANCE
AOOL
INSD
SO
4.
POLICY NUMBER
WVUDD/YYYY
MM/DD11'YVY
LIMITS
A
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
S 2,000,000_
CLAIMS -MADE OCCUR
P100.087.007.3
02/05/2024
02/05/2025
AU GWE
PREMfSES i6a.. ONC."uraa"ca7
$ 100,000
MED EXP (Any one person)
$ 5,000
''. PERSONAL & ADV INJURY
$ 2,000,000
2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
GE NERALAGGREGATE
S
PRODUCTS-COMP/OP AGG
$ 2,000,000
POLICY O TO' ] LOC
ECA
$
01f-0 ER':�
AUTOMOBILE LIABILITY
COMEWED SINGLE LIMIT'
Ea accident
$
BODILY INJURY (Per person)
$
ANY AUTO
.............
OWNED SCHEDULED
BODILY INJURY (Per accident)
$
AUTOS ONLY AUTOS
'. HIRED '. NON -OWNED
P B DIPY
AUTOS ONLY AUTOS ONLY
dbP kWC code nq
UMBRELLA LIAB
OCCUR
EACH OCCURRENCE
$
AGGREGATE
$
EXCESS LIAB
CLAIMS -MADE
''.
DED RETENTION $
$
WORKERS COMPENSATION
O H
STATUTE ER
AND EMPLOYERS' LIABILITY Y / N
ANY PROPRIETOR/PARTNER/EXECUTIVE I""�""""'J
E.L. EACH ACCIDENT
$
OFFICER/MEMBER EXCLUDED?
NIA
DY
(Mandatory in NH)
E.L. DISEASE - EA EMPLOYEE
$
E,L.. DISEASE - POLICY LIMIT
S
IF yes, describe under
DESCRIPTION OF OPERATIONS below
A
Professional
P100.085.370.3
02/05/2024
02/05/2025
Aggregate
$1,000,000
Liability
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required)
CERTIFICATE HOLDER CANCELLATION
City of El Segundo
F350 Main St SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
El Segundo, CA 90245 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
! 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
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:
. usaa.com,
. USAA's Mobile App, or
. By calling 210-531-USAA (8722), our mobile phone shortcut number #8722 or
800- 5 31 - USAA.
California Evidence of Financial Responsibility
This ID card is evidence of liability insurance for your vehicle. The card is valid only as long as liability
insurance remains in force. Keep a copy of the ID card in your vehicle at all times.
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.
FCA1 Rem. 6-13
CALIFORNIA EVIDENCE OF FINANCIAL RESPONSIBILITY
Name and Address of Insured NAIC 25968
KRISTEN BERGEVIN
1142 S HOLT AVE APT 3
LOS ANGELES CA 90035-2423
f
0
1
d
KRISTEN BERGEVIN
Insurance company
USAA CASUALTY INSURANCE COMPANY
Policy Number Effective Date Expiration Date
00748 27 03C 7101 1 06/01 /24 12/01 /24
Vehicle Make/Vehicle , ber Zoos
e
This policy provides at least the minimum amounts of liability insurance
required by the CA VEH CODE SECTION 16056 for the specified vehicle and
named insureds and may provide coverage for other persons and other
vehicles as provided by the insurance policy.
50781-0513 02
-
--------------back_ -_------_.......----.._.._...
California Evidence of Financial Responsibility
Keep this card.
IMPORTANT: The California Financial Responsibility
Act (Section 16020) of the Vehicle Code requires every
owner or operator of a vehicle subject to the
requirements of the Financial Responsibility Act to carry
evidence of financial responsibility in the vehicle at all
times. Under vehicle code (Section 16028) every driver
involved in an accident must provide evidence of
financial responsibility at the scene. Failure to comply is
an infraction and shall be punishable by fines,
impoundment or license suspension.
Additional copies available at usaa.com
CONTACT US: 210-531-USAA(8722)
OR 800-531-USAA
9800 Fredericksburg Road, San Antonio, Texas 78288
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.
C_) 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 sub' ct to the orkers' compensation provisions of Labor Code § 3700 1 must
immediately comply with those provisory orie Ireement automatically become void.
Signature of Applicant ....
Print Name Kristen Bergevin
Agreement for:
taps)
"-"'i
Dated:6P§J?4
Reviewed by:
Date
2/8/2021