PROOF OF INSURANCE (2025 - 2025) CLOSEDA F40M ia'ERIERAL INSURANCE COMPANY
;'�GWPANY WITH HOME OFFICES IN BLOOMINGTON, ILLINOIS
�r 2.9tofr4n IL 61702-2915
Named Insured
ATz 003273 3125 M-23-1354-FA75 F N
WELL, CAROL
214 W MAPLE
o
Businessowners Policy
RENEWAL DECLARATIONS
Policy Number 92-J2-0525-2
Policy Period Effective Date Ex iration Date
12 Months SEP 1 2024 SEPP 1 2025
The poll y period begins and ends at 12:01 am standard
time ate premises location,.
Agent and Mailing Address
EIS BARNHART
502 MAIN ST
EL SEGUNDO CA 90245-3069
PHONE: (310) 322-8911
Automatic Renewal - If the policy period is shown as 12 months , this policy will be renewed automatically subjectto the premiums, rules and
forms in effectfor each succeeding policy period. If this policy is terminated, we will give you and the Mortgagee/Lien holder written notice in
compliance with the policy provisions or as required by law.
Entity: Individual
NOTICE: Information concerning changes in your policy language is included. Please call your agent
if you have any questions.
POLICY PREMIUM $ 325.00
Minimum Premium
Discounts Applied:
Renewal Year
Years in Business
Claim Record
Prepared
JUN 19 2024 OcCopyright, State Farm Mutual Automobile Insurance Company, 2008
CMP-4000 Includes copyrighted material of Insurance Services Office, Inc., with its permission.
022W2 294 1 Continued on Reverse Side of Page
E ? Y, L7
Page 1 of 7
530-585 a 05 31 2011 101132310 1
INSURANCE WAIVER
Pursuant to Section 4 of El Segundo City Council Resolution No. 4813, the undersigned
authorized the waiver of commercial auto insurance for the City of El Segundo instructor
contract with Carol Well.
Date:
—Ot2r-
By: ��X4==A
Darrell George, City Vanager
tTm CALIFORNIA
INSURANCE CARD
State Farm Mutual Automobile Insurance Company
PO Box 2358 Bloomington IL 61702-2358
INSURED WELL, CAROL MUTL
VOL
POLICY NUMBER P36 0856-A29-75F EFFECTIVE
YR 2006 MA<E TOYOTA UUL 29 211j 71) JAN 29 2025
MODEL CAMRY vm 11
NGENT ED BARNHART
PHONE 318 !0 NAIC 25178
COVERAG_ PR
PR' 322,8911 VIDED BY THE POLICY MFETS THE MINIMUM LBASRITY LIMITS
EMEICRIB ED BY LAW
RAGES A C D G100 H R I! U 0 1
SEE REVERSE SIDE FOR AN EXPLANATION.
In CALIFORNIA
INSURANCE CARD
State Farm Mutual Automobile insurance Company
PO Box 2358 Bloomington IL 61702-2358 MLITL
INSURED WELL, CAROL VOL
POLI CY N U M 13 E 8 p3.6 oa,56 - A 29.7 5F
YA Zoos MAKT, JOYOTA JUL292025
MODEL CAMSY VIN
AGENT ED BARNHART
A10? -8911 POLICY MINIMUM LIABILITYLIMITS
PHONE N2 NMO 251,76
COVERAG PR VIDCDOYTHEPOL EFTS THE
C A R SEE REVERSE SIDE FOR AN EXPLMAVON 016'I'TIN A C 0 G100 H RI U UI
.�.,
C11 i Vr CL JCl7U1YUV
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 polir_.y number are.:
Carrier
Policy Number Expiration Date
Name of Agent Phone #
O I certify that, in the performance of the work set forth in the agreement with the Citv 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 sq ject to the workers' compensation provisions of Labor Code § 3700 1 must
immediately
ApplicantPY with those comply se p r66sions or the afr;emer�t5 w II �QornaticaNly become void.Date
Signature
f
Pri t Name
Agreement for:
Dated:
Reviewed by: