PROOF OF INSURANCE (2025 - 2025) CLOSEDit ialdlh% k"4'afiet
Atoro.ISe_3pc` ce l'�ack r"a;`. try i u.,t"t svtll panucrlsatc In the
(tgofl ,',tu. r,F,V"itItl pdo;n%r»x,,Nph4araWtvId'Fesnvalof
I lolulays event I:ihc " went") par�Innl to all agrevnl rll wrlh Ilk-
Cily, Contractor understands that participation In tht Ev"I rc not
ulthmi.rill" toculanbellnand otllcn Thescemludc_wllYwut
htnxlation, mkt of physical Injury, irwriLil tn)ury, ernc4wnil distress,
trauma, death, cvniaca with t ihcr panaupanb, and properly datnngc
All risks are know-r and appceeialed by Contractor. C onixactor
uai%v5 any and all spccrfic notice of the oxrurnce of risks
CunEw ur uwrncs xcspomtbdtly fug ail will luy lit arryl rucdreal
and emeq".'.Wy tzpcnvts in the es en1 of injury. Illness, nr other
Incapaelty IvpWdIc" ut whelhci I autlt4f11C411 Sixti CXPCIISCS
`Cuutiactw- mcludcs ConlracW% cniploycn, ulliccn. or olio
agents.
Contra.ug agrees and rcprvscr& That it Im impeded, or
tmlr"uIely upm entering Main St City I tall Playa, will inspecl
the prolmwi am] factlnta throulthour the hseni Concumor's entry
onto poblx properry for all puryioscs assotiattd said) Rhe F.ycm
comUll„" m acknu Iedgmclt; that •uch piclillwN and all laclil[Ic>
and equtpmern wine im Ncud aril slut Conimcicr finds and accepaA
therm as being safe and reasoraabty suited for the purposes of
Conur tm'a purticlpahnn in the Event
By read=nit. slgsn g ail daling Ihrs diecunwIA. C'I:inrla:n+r licroby
ware,. rcicascs, dnchaNcS, and avwenanis_ not to sue aif hold
hannlcsi dic Cily of El Sq;ondv. m officials, aµenlc, sponsuts_
an1or Lrrtployecs 1'Relcaarrs''1 troni and all darnagca, loxscs, firers.
claims, Satins, rspcn%cA (including attocney fees and defew costs for
Council ae.eplaldt to(:Ily), judgments "'ot liabiliticsof any form
or name: m%litnkt from Cmluacanr's negligence, masconlucl. as
pantcipauon in theevem, wbxh inchides, abbot hmuaxion
Contractor's IrasYl us and (foul Olt Even(, %*Ibcf by sehu;le nr
sober means Ibis rclt;.sc of liability nhlndrs, but is rxx tinned to
any voury. death, sickness uc perwuA Inluly or prttprrty danasbr
Contractm may suffer while on or mound the prcmrxs -where the
Cscnl is held. This rcBcasa ulso includcs specrlically, but without
limilation, any and all hums of petssxul injury r oJuding death) and
plvperty ski natty to any per colt. rrsulung kvlr Collsraelor's
ncgligrocc, nut cor duel. ur Wiciprtivn in IL- w cut, w h0l
nwludcs. widlout hina4lionContraclm'a ua�el goJod 1191n the
F%cnl,whethcrbyvchwicor ,kdcr ow Ar, _,7u4Corurac-4-Ts 1 e:,wty
assunic the nsk• of such drmar..^,, oe air ....s Auld Sossca
any pansciparton in the ksrnt. Contractor apecs that the foregoing
tc)tasc and 11'a11'rf is intclided io be as Fecad as IncluSive as
pcnmllcd under dais of Callttwnla law ail Out. 11 any ponron Is
held lnvand, it is agrctd that the balance will, n twilhotandrng.
continue so full lgal for sc and eticxt
The undcntgncd wagganis that he or .she has legal authonty, to bind
Contm-tor and that C onlrActor fully unlenlands and agrees to the
abosv term, and cotxlabom In cnrtiadtmdM for Ni, Fvsnt and
further a V l;` L 4^ vial rrpfCSC91ia[I1115, blalcniCN-1, W Induecnlcni
apart 1�,A writ^,r have Men maJ,
l'kI
DATE
FOOD
LIABILITY
INSURANCE
G' AIUSURA
PROGRAM
uumEm aouv
CEGROUP
Ip1z Pown^e , ^�u Yl� r J rr urp,
Great American Alliance Insurance Company
844-520-6992
E. Street, 25 S
Powered by Veracity Insurance
OH 45202-4201
Cincinnaati,ti, O
n
Solutions, LLC
COMMERCIAL GENERAL LIABILITY COVERAGE PART - OCCURRENCE FORM
CERTIFICATE PAGE
IT IS AGREED THAT THIS CERTIFICATE IS ISSUED TO THE CERTIFICATE HOLDER LISTED BELOW TO CERTIFY COVERAGE
UNDER THE COMMERCIAL GENERAL LIABILITY INSURANCE MASTER POLICY LISTED BELOW.
INSURANCE COMPANY: GREAT AMERICAN ALLIANCE INSURANCE COMPANY POLICY NUMBER:
NAMED INSURED: HOSPITALITY & ENTERTAINMENT TRADE ALLIANCE PLF046122
CERTIFICATE HOLDER: Dokken Consulting, LLC. DBA Atomic Space Snacks CERTIFICATE NUMBER:
ADDRESS: 14607 Hardaway Dr, La Mirada, California 90638 F240247
POLICY PERIOD: 04/05/2024 to 04/05/2025 12:01 AM Standard Time at the Address of The Certificale Holder
LIMITS OF INSURANCE
General Aggregate Limit (Other than Products -Completed Operations) S 2.000,000
Products -Completed Operations Aggregate Limit S 2,000,000
Personal and Advertising Injury Limit $ 1,000,000
General Each Occurrence Limit $ 1.000,000
Damage to Premises Rented to You Limit $ 300,000 Any One Premises
Medical Expense Limit $ 5,000 Any One Person
Professional Coverage Extension $ Not Purchased Each Claim
$ Not Purchased Aggregate
Professional Coverage Deductible $ Not Purchased Each Claim
Liability Deductible None
FORM OF BUSINESS: LLC
PREMIUM:_ $ 169
BHTA Fee: $ 162.3
TOTAL ANNUAL COST: $ 331.3 (The cost Is 100%earned1non refundable)
CODE NUMBER: 11168 PREMIUM BASIS: Gross Sales EXPOSURE: Up to $50,000
BUSINESS DESCRIPTION: Vendor, Distributor, or Manufacturer of food products; Concessions, Farmers Market Vendor,Home-
Based Baker,Food Manufacturer, Food Distributor
THIS INSURANCE IS SUBJECT TO ALL THE TERMS AND CONDITIONS, INCLUDING APPLICABLE ENDORSEMENTS, OF THE
COMMERCIAL GENERAL LIABILITY INSURANCE MASTER POLICY. A COPY OF THE COMMERCIAL GENERAL LIABILITY
INSURANCE MASTER POLICY ACCOMPANIES THIS CERTIFICATE, ADDITIONAL COPIES WILL BE PROVIDED TO THE
CERTIFICATE HOLDER. PLEASE READ THE POLICY AND ALL ENDORSEMENTS.
NO ADMISSION OF LIABILITY MAY BE MADE EITHER VERBALLY OR IN WRITING
FULL DETAIL OF ANY INCIDENT SHOULD BE SENT IMMEDIATELY BY EMAIL TO CLAIMMYQPVNS _qM OR BY LETTER
_ TO VERACITY INSURANCE SOLUTIONS, LLC 260 SOUTH 2500 WEST SUITE 303, PLEASANT GROVL, UT 84062,,
FORMS AND ENDORSEMENTS applicable to all Coverage Parts and made part of this Policy at time of issue are listed on
the attached Forms and Endorsements Schedule IL 88 01 (11/85),
ADMINISTRATED BY,
Veracity Insurance Solutions, LLC
260 South 2500 West Suite 303
Pleasant Grove Utah 84062
888-568-0548
1fv�oL�e�tEi a�mron7,crn5.
ADMINISTRATOR'S SIGNATURE;, ' ',
State Farm Mutual Automobile Insurance Company
PO Box 2358
Bloomington IL 61702-2358
AT2 A-2CD3
JESSICA ANN DOKKEN
Policy Number: 680 2807-1303-75A
Policy Period: August 3, 2024 to February 3, 2025
Vehicle:
2020 TOYOTA 4 RUNNER
Principal Driver:
JESSICA A DOKKEN-HERRON
n
Notice of insurance information collection practices -
personal, family, or household insurance transactions:
We may collect customer information from persons other
than the individual or individuals applying for coverage.
Such customer information as well as other personal or
privileged information subsequently collected may, in certain
circumstances, be disclosed to third parties without your
authorization as permitted by law.
Policy Number: 680 2807-B03-75A
Prepared June 12, 2024
1004583
AUTO RENEWAL
PREMIUM PAID: $743.22
DO NO IF IIFAY
Your premium is billed through the State Farm Payment Plan
State Farm Payment Plan Number: 1286787323
Your State Farm Agent
SUZY ZIMMERMAN INS FIN SVS INC
Office: 310-377-9531
Address: 4010 PALOS VERDES DR N STE 103
RLLNG HLS EST, CA 90274-2567
If you have a new ordtlferent car, have added any diiver4 orhave moved,
please contact your agent.
Thank you for choosing State Farm.
You have the right to submit a written request to access,
correct, amend, or delete your personal information and the
right to receive a response within 30 days of submitting your
request. If we deny your request, you have the right to file a
statement with us containing the information you feel is
accurate and fair along with the reasons you disagree with
our denial. Instructions on how to file such request and our
full privacy notice can be found
(continued on next page)
Page number 1 of 5
143562 202 01-15-2018
You mean a lot to us. If you need anything,
call State Farm° Agent SUZY
,G 377 9531.
TP31
www.statefarm.com/customer-care/privacy-security/privacy
or contact your State Farm Agent.
Your auto insurance rates are impacted by the mileage your
vehicle is driven. To ensure we've priced our insurance
coverage accurately based on the number of miles you
drive, we obtained valid mileage information for this vehicle
through a third party provider and/or from you. Annual
mileage was determined using this data and applied. Please
contact your State Farm agent with questions within 30 days
of your policy's renewal date.
EII[CIDIt,llE INFO M PION
When you provide a check as payment, you authorize us
either to use information from your check to make a
one-time electronic fund transfer from your account or to
process the payment as a check transaction. When we use
information from your check to make an electronic fund
transfer, funds may be withdrawn from your account as soon
as the same day we receive your payment, and you will not
receive your check back from your financial institution.
Review your policy information carefully. If anything is incorrect, or if there are any changes to your vehicle information, please
let us know right away.
Vehicle Identification
Vehicle Description Number (VIN) Who principally drives this vehicle? How is this vehicle normally used?
2020 TOYOTA 4 RUNNER JESSICA DOKKEN- To Work, School or Pleasure.
Other Household Vehicle(s)
Your premium may be influenced by other State Farm
policies that currently insure the following vehicle(s)
in your household:
2007 CHEVROLET C1500
2011 FORD EDGE
The premium on the expiring policy term was based on
13,900 miles per year.
The premium on the renewal policy term was based on
15,100 miles per year.
Premium Adjustment
Each year, we review our medical payments and personal
injury protection coverages claim experience to determine
the vehicle safety discount that is applied to each make and
DRIVER, INFORMATION
IIF'.I A'nlwlIO
Other Household Driver(s)
In addition to the Principal Driver(s) and Assigned
Driver(s), your premium may be influenced by the
drivers shown below and other individuals permitted to
drive your vehicle. This list does not extend or expand
coverage beyond that contained in this automobile
policy. The drivers listed below are the drivers reported
to us that most frequently drive other vehicles in your
household.
NELLY HERRON
model. In addition, we review the comprehensive, collision,
bodily injury and property damage claim experience
annually to determine which makes and models have
earned decreases or increases from State Farm's standard
rates. If any changes result from our reviews, adjustments
are reflected in the rates shown on this renewal notice.
Policy Number: 680 2807-B03-75A Page number 2 of 5
Prepared June 12, 2024
Principal Driver & Assigned Drivers
For each automobile, the Principal Driver is the individual
who most frequently drives it.
Each driver is designated as an Assigned Driver on the
household automobile that they most frequently drive. Your
premium may be influenced by the information shown for
these drivers.
COVIII,,, I GE N Ilia t..l i'HE III"I" fit See your policy for an explanation of these coverages.
A Liabil
Bodily Injury 100,000/300,000
Property Damage 100,000
$276.86
C
Medical Payments 5,000
$9.62
D
500 Deductible Comprehensive
$120.51
G
500 Deductible Collision
$278.17
H
Emergency Road Service
_ $3.14
R1
Car Rental & Travel Expense
$25 Per Day, $600 Max
$21.83
U
Uninsured Motor Vehicle
Bodily Injury 30,000/60,000
$29.94
U1
Uninsured Motor Vehicle
Property Damage
$3.15
Total Premium
$743•22
If any coverage you carry is changed to give broader
protection with no additional premium charge, we will give
you the broader protection without issuing a new policy,
starting on the date we adopt the broader protection.
I)IIISC 0 t) IN"I1"t3 These adjustments have already been applied to your premium,.
Multiple Line
Multicar
Vehicle Safety
Driving Safety Record ✓"
California Good Driver "`
Loyalty
Totah Discounts $3,142.16
SURCHARGES AND IDISCOUNH'S
Driving Safety Record Rating Plan
Your driving safety record, along with other rating factors,
determines what you pay for Liability, Medical Payments,
Comprehensive, Collision, and Uninsured Motor Vehicle
Coverages. Policyholders with no accidents and convictions
pay less than those with accidents and convictions.
The Driving Safety Record Rate Level that is assigned to
your policy moves up, down, or stays the same every policy
(continued on next page)
Policy Number: 680 2807-603-75A
Prepared June 12, 2024
Page number 3 of 5
renewal, depending upon your driving record. For every 12
months since the renewal following the occurrence of a
chargeable accident or the conviction of a minor violation,
the initial assigned Driver Record Level for that chargeable
accident or conviction shall be lowered by 1 level. For each
12 month period since the conviction of a major violation,
the initial assigned Driver Record Level for that conviction
shall be lowered by 2 levels. The Rate Level is increased if
there are subsequent chargeable accidents or convictions.
Definition of Chargeable Accidents
Chargeable accidents for new business are those which
resulted in bodily injury or death or in payment(s) by an
insurer due to damage to any property in the amount of
mare than $1000. For accidents occurring prior to
December 11, 2011, an accident shall be chargeable
provided it resulted in death or in payment(s) by an insurer
A [1 nivl 111"'1110 N A L. I IN IF C I"t M A"'1'° I C N
due to damage to any property in the amount of more than
$750.
For applicants without prior insurance at the time of the
accident, an accident shall be chargeable provided it
resulted in damage to any property in the amount of more
than $1000 (more than $750 if the accident occurred prior to
December 11, 2011).
Chargeable accidents for renewal business are those which
resulted in bodily injury or death or State Farm claim
payments totaling more than $1000 (more than $750 for
accidents occurring prior to December 11, 2011) under
property damage liability coverage and collision coverage
combined.
For more information about the rating plan, please contact
your State Farm agent.
Superior Driver Rate Level
IMPORTANT NOTICE If any information on this renewal notice is incomplete or
For your protection California law requires the inaccurate, or if you want to confirm the information we have
following to appear with this policy: Any person who in our records, please contact your agent. For additional
knowingly presents false or fraudulent information to information regarding discounts or coverages, see your
obtain or amend insurance coverage or to make a claim State Farm agent or visit statefarm.com®.
for the payment of a loss is guilty of a crime and may be
subject to fines and confinement in state prison.
lururi ourtarmt Notice IRegaui'ding Youir Pireimkinin
State Farm works hard to offer you the best combination of price, service, and protection. The amount you pay for automobile
insurance is determined by many factors including:
• The coverage you have
• Where you live
• The kind of car you drive
• How the car is used
• Who drives the car
Any premium adjustment is reflected on this Auto Renewal. If you have any questions, please contact your agent.
Euying a new oar? II?ernerm bear to contact your agent!
When you buy an additional car or one that replaces a car already on your policy, you need to report the change to your agent
promptly. Even though the dealership you purchased the car from may offer to notify your agent or insurance company, you, as
the named insured, are responsible for reporting all changes to your auto policy. By contacting your agent, you can help:
• avoid any complications or lack of coverage in the event of an accident or loss,
• avoid insurance verification problems with a lienholder, the police, or the department of motor vehicles, and
• ensure that you receive any new discounts you may be entitled to.
Your current State Farm policy automatically provides certain coverages for a new or replacement car for up to a specified, limited
number of days after you take possession of the car. Please refer to your policy for the number of days that applies in your state.
If you have any questions about coverage for a newly acquired car, please contact your State Farm agent.
(continued on next page)
Policy Number: 680 2807-B03-75A Page number 4 of 5
Prepared June 12, 2024
Disclaimer: This message is provided for informational purposes only and does not grant any insurance coverage. The terms and
conditions of coverage are set forth in your State Farm Car Policy booklet, the most recently issued Declarations Page, and any
applicable endorsements.
Policy Number: 680 2807-1303-75A Page number 5 of 5
Prepared June 12, 2024
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.
(_) 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 #
( 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 Applicant
�Date 11/18/24
Print Name Jcpica Dok en
Agreement for:
Dated:
Reviewed by: