PROOF OF INSURANCE (2025 - 2025) CLOSEDGFx-E 1
11990RARCE COIER1e1ES
Great American Alliance Insurance Company
301 E. Fourth Street, 25 S
Cincinnati, OH 452024201
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: BEAUTY HEALTH & TRADE ALLIANCE PLF047372
CERTIFICATE HOLDER: Bee Accessories Boutique Bee Accessories Boutique CERTIFICATE NUMBER:
ADDRESS: Bee Accessories Boutqiue 2464 Kansas Ave, south Gate, California 90280 AA280707
POLICY PERIOD: 03/07/2024 to 03/07/2025 12:01 AM. Standard Time at the Address of The CerttfCate Holder
LIMITS OF INSURANCE
General Aggregate Limit (Other than Products -Completed Operations)
$
2,000,000
Products -Completed Operations Aggregate Limit
$
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
Liability Deductible
None
Professional Coverage Extension
$
Not Purchased Each Claim
$
Not Purchased Aggregate
Professional Coverage Deductible
$
Not Purchased Each Claim
FORM OF BUSINESS: LLC
PREMIUM: $ 169
BHTA FEE: $ 147.75
TOTAL ANNUAL COST: $ 316.75 (The cost is 100% earned/non refundable)
Price includes premium and fees _
CODE NUMBER: 51970 PREMIUM BASIS: Gross Sales EXPOSURE: Up to $50,000
CLASSIFICATION: Jewelry
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 DEl'Ali. OF ANY INCIDENT SHOULD BE. SENT IMMEDIATELY BY EMAIL 'TO_QLAIM a1 OPI Q IA OR BY LETTER
TO VERACITY INSURANCE SOLUTIONS, LLC 260 SOUTH 2500 WEST SUITE 303„ P� ASANT GROVE, 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).
ADMINISTRATOR'S SIGNATURE:
ADMINISTRATED BY
Veracity Insurance Solutions, LLC
". AI 260 South 2500 West Suite 303
,» Pleasant Grove Utah 84062
CA Insurance Identification Card
NAMED INSURED POLICY
BEATRIS CEJA CAAS227219520
EFFECTIVE DATE
Jun 02, 2024
There maybe other drivers EXPIRATION DATE
listed on your policy. Jun 02, 2025
KEEP THIS
COPY
IN
YOUR
VEHICLE
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 11/20/2024
Print Name Beatris Ceja
Agreement for:
Dated:
Reviewed by:
Y
� fl: =.. rol M -MIN
December 5, 2024
Liability Waiver
Bee Accessories _ ("Beatris Ceja") will participate in the City of El Segundo's ("City") Joy Around the
World/Festival of Holidays event (the "Event") pursuant to an agreement with the City. Contractor
understands that participation in the Event is not without risk to Contractor and others. These include,
without limitation, risks of physical injury, mental injury, emotional distress, trauma, death, contact with other
participants, and property damage. All risks are known and appreciated by Contractor. Contractor waives any
and all specific notice of the existence of risks. Contractor assumes responsibility for and will pay (if any)
medical and emergency expenses in the event of injury, illness, or other incapacity regardless of whether I
authorized such expenses. "Contractor" includes Contractor's employees, officers, or other agents.
Contractor agrees and represents that it has inspected, or immediately upon entering Main St./ City Hall
Plaza, will inspect the premises and facilities throughout the Event. Contractor's entry onto public property
for all purposes associated with the Event constitutes an acknowledgment that such premises and all facilities
and equipment were inspected and that Contractor finds and accepts them as being safe and reasonably
suited for the purposes of Contractor's participation in the Event.
By reading, signing and dating this document, Contractor hereby waives, releases, discharges, and covenants,
not to sue and hold harmless the City of El Segundo, its officials, agents, sponsors, and/or employees
("Releasees") from and all damages, losses, fines, claims, suits, expenses (including attorney fees and defense
costs for Council acceptable to City), judgments and/or liabilities of any form or nature resulting from
Contractor's negligence, misconduct, or participation in the event, which includes, without limitation
Contractor's travel to and from the Event, whether by vehicle or other means. This release of liability includes,
but is not limited to any injury, death, sickness or personal injury or property damage Contractor may suffer
while on or around the premises where the Event is held. This release also includes specifically, but without
limitation, any and all forms of personal injury (including death) and property damage to any person, resulting
from Contractor's negligence, misconduct, or participation in the event, which includes, without limitation
Contractor's travel to and from the Event, whether by vehicle or other means, and Contractor expressly
assume the risk of such damages or injuries and losses throughout any participation in the Event. Contractor
agrees that the foregoing release and waiver is intended to be as broad as inclusive as permitted under state
of California law and that, if any portion is held invalid, it is agreed that the balance will, notwithstanding,
continue in full legal force and effect.
The undersigned warrants that he or she has legal authority to bind Contractor and that Contractor fully
understands and agrees to the above terms and conditions in consideration for the Event and further agree
that no oral representations, statements, or inducement apart from the foregoing written agreement have
been made.
SIGNED: Beatris Ceja PRINTED:Beatris
Ceja
DATE: 12