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PROOF OF INSURANCE (2024 - 2025) CLOSEDAC"M"' CERTIFICATE OF LIABILITY INSURANCE
DATE (MWDDfYYYY)
IL.�
09/09/2024
PRODUCER
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY
AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
Alberto 0 0 -on
CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE
do St. Ste F
828 E, Colorado
COVERAGE AFFORDED BY THE POLICIES BELOW.
Glendale, CA 91205
Ph. (818) 507-9705 Fax: (8 t8) 662-9996
INSURERS AFFORDING COVERAGE _._N.A1C
#
............ . .....
INSURED
INSURER A: Scottsdale Insurance Corrionay
41297
Bubblennania and Company Inc,
INSURER B: ........................... ...... .
. .......
12405 Venice 131vd #384
INSURER C:
Los Angeles, CA 90066
INSURER D: .. . . . ..............
INSURER E: I.
f'r%11r_DA1-_CQ
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS .................... . . __ ..........
P666V'6FFECTiV'_E . ...... . P"0__[1_GYEXPIRATION k T POLICY NUMBER DATE (MMIDDNY) LIMITS
INSRU TYPE OF INSURANCE (MMIDDfYY DATE
.LTR
A
0
GENERAL LIABILITY
CPS7897648
12/01/2023
l2/0(/2024
EACH OCCURENI�!.
$1,000,000
1E COMMERICAL GENERAL LIABILITY
DAMAGE TO RENTED
1100,000
[I DCLAIMS MADE 0 OCCUR
k ED = P (Any one person)
$5,000
PERSONAL & ADINJURY
n n u c) n 0
GENERAL AGGREGATE
s2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGO
$2,000,0010
POLICY[] PROJECT[:] LOG
Abuse & sexual Molestmon
$ 1,000,000
❑ANY
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
$
(Each Occurrence)
AUTO
F-1 ALL OWNED AUTOS
BODILY INJURY
$
(Per person)
SCHEDULED AUTOS
F-1 HIRED AUTOS
BODILY INJURY
F1 NON -OWNED AUTOS
(Per accident)
_1 11-1 . ....... . .................... .
$
......... — - -------------
PROPERTY DAMAGE
(Per accident)
$
❑
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT
$
EIANY AUTO
OTHER THAN EA AGO
$
F-1
AUTO ONLY: AGO
$
EXCESSIUMBRELLA LIABILITY
EACH OCCURRENCE
$
OCCUR [—] CLAIMS MADE
AGGREGATE
.
$
. ..... . ...
F-1 DEDUCTIBLE
. .....
❑ RETENTION S
WORKERS COMPENSATION AND
U- OTH-
WC STATUS
L-J ERmm
❑
EMPLOYERS' LIABILITYTORY
ANY PROPRIETOR/PARTNERIEXECLL
E L_ EACH ACCIDENT
TIVE OFFICERIMEMBER EXCLUDED?
E. L, DISEASE - EA EMPLOYEE
s
ir yes, describe under
.......
SPECIAL PROVISIONS below
E.L. DISEASE - POLICY LIMIT
$
❑ OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS i VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT t SPECIAL PROVISIONS
Additional frisured: The City of El Segundo, its ofrcers, officials, employees, agents, and volun�eers
SHOULD Th- �:Hy ji 7;L S=q�Ao _FSHO1 LD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE INSURER AFFORDING COVERAGE WILL ENDEAVOR TO
MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT
FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE
INSURER. ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATW9
ACORD 25
Alberto 0 Ocon
@ ACORD CORPORATION 1988
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this
certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
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).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contact between the issuing
insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively
amend, extend or alter the coverage afforded by the policies listed thereon.
ACORD 25 f Q4
POLICY NUMBER: CPS7897648 COMMERCIAL GENERAL LIABILITY
CG 20 26 07 04
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
Section II — Who Is An Insured is amended to in-
clude as an additional insured the person(s) or or-
ganization(s) shown in the Schedule, but only with
respect to liability for "bodily injury", "property dam-
age" 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:
A. In the performance of your ongoing operations; or
B. In connection with your premises owned by or
rented to you.
CG 20 26 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 0
'E�/ ISloli1ly
VE This ID card is evidence of liability ity insurance for your veill�.ale The card is valid onl as Ion
i/j% '" " insurance
,remains in force. Keep a copy of the ID
��,a�l rRaPd in your vehicle at all�times.g as liability
You may be required to per°rraiice Yow identification card
' applying for a driver's license,following an accident, or uatovehicle registration or inspection, when
upon a law enforcement officer's request.
FCA 1 Re.v. 6 - 13
50 781- 051 3 02
-----------------------------------------------
-------------
CALIFORNIA EVIDENCE OF FINANCIAL RESPONSIBILITY
Name and Address of Insured NAIC 25968
CAREY PICKFORD California Evidence of Financial Responsibility
Keep this card
IMPORTANT: The California Financial Responslbit;ity
Act (Seal on 16020) of the Vehicle (de requires every
CAREY PICKFORD
GINA PICKFORD
CAREY PICKFORD JR
SOPHIE PICKFORD
CARLA PICKFORD
Insurance Company
USAA CASUALTY INSURANCE COMPANY.
Policy Numbe11 r Effective Date Expiration C
00645 41 OOC 7101 6 I 08/03/24 02/03/25
Vehicle Make/Vehicle Iden " Ii G"on 'R �ber year
2019
TOYOTAa
" liatillity insurance
j This policy provides at least the minimum amounts of specified vehicle and
��jequlred by 'the CA VEH CODE SECTION 16056 for the P
Gff' dmad_,insureds and _maw .nrrnrirlo' nnvorano for other per5on5 and other
UVIU01KwO Vi II11cili of 1 z5yU1iz)1Uniyy m o1�,uyg
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;carn,
CONTACT US: 210-531-USAA(8722)
OR 800-531-USAA
9800 Fredericksburg Road, San Antonio, Texas .7a288%
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 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 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 ApplicantDate 9/30/24
Print Name
Joseph Ferri `
Agr
eement for: 9W
Dated- 11I 1 Lb
Reviewed by: