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PROOF OF INSURANCE (2025)THE CERTIFICATE .E ,,... LD THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON TE OF LIABILITY INSURANCE 01/16/2025 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 be endorsed. If SUBROGATIONIS 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), NUTMEG INS AGENCY INC/PHS Nam!. -- — 76210797 PHONE (888) 925-3137 FAX (AIC, Na): (AIC, No, Ext): The Hartford Business Service Center 3600 Wiseman Blvd E-MAIL San Antonio, TX 78251 ADDRESS: •••••mm INSURER(S) AFFORDING COVERAGE NAIC# IA6SUREO ................. INSURERA:....... Harif'Ord Underwriters Insurance Company 30104 Nathan John DBA Kweku Abimbola ....... mm INSURER B :. 3060 W OLYMPIC BLVD APT 717 -. • """ ""' " LOS ANGELES CA 90006-3845 INSURER C INSURER D ...INSURER E t.....-_..... .................. .�_.. ......... INSURER F : COVE.....�... .......... _..... __ ......_... RAGES CERTIFICATE NUMBER: 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. IN'S TYPE OF INSURANCE ADOL SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS TR .. ........—._..... INSR WVD _ ... _ rMYYY kI (Y. Y COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000 NTEO �I" ..,..., DAMAGEMA E TO RFone person) $1,000,000 CLAIMS -MADE IIL ... OC<TN.1R. I rn 0,000 X General Liability MED EXP (Any A _ ... X 76 SBU BM6KBA 12/11/2024 12/11/2025 PERSONAL ,$AOVINJURY $1 000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000'.,000 X POLICY' PRO LOC PRODUCTS - COMP/OP AGG $2,000,000 PRO- ...... .... ..... OTHER: _ $1,000„00C AUTOMOBILE LIABILITY • �•-•_��• .� COMBINED SINGLE LNIWIIT ANY AUTO BODILY INJURY (Per person) ALL OWNED SCHEDULED A AUTOS AUTOS 76 SBU BM6KBA 12/11/2024 12/11/2025 BODILY INJURY (Per accident) _ OAMAGE .....• X HIRED X NON -OWNED (Praccident) AUTOS AUTOS ( _....... ......._. ._........_......... ..... .... ....... UMBRELLA LIAB "OC'CUR EACH OCCURRENCE EXCESS LIAR CLAIMS- AGGREGATE L. MADE DEO RETENTION $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS' LIABILITY ,STATUTE E.R. ........... .-... ANY YIN E.L. EACH ACCIDENT PROPRIETOR/PARTNER/EXECUTIVE N/A OFFICER/MEMBER EXCLUDED? E.L. DISEASE -EA EMPLOYEE (Mandatory in NH) ........-... ........ �.. ......... If yes, describe under E,.L. DISEASE -POLICY LIMIT .._........... ..... m. DESCRIPTION OFr, P:E„ RATIONS bakldawe'..... ........ ....... ..._.. ........�.,.. ......... ......— DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICL • ES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Those usual to the Insured's Operations. Certificate holder is an additional insured per the Additional Insured - Designated Person Or Organization Form SL3042 attached to this policy. ._.__. CERTIFICATE HOLDER ...... ANCELLATIOI` _ City of El Segundo SHOULD ANY OFTHE E ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION 350 MAIN ST NOTICE WILL BE DELIVERED EL SEGUNDO CA 90245-3813 IN ACCORDANCE WITH THE POLICY PROVISIONS. _.................... AUTHORIZED REPRESENTATIVE �u®-�n � C�Zaze�� .._.._.._.._.......-... _.... .......... __...0 1988 2015 ACORD CORPORATION. All rig hts reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD THE HARTFORD NATHANJOHN Policy Information: Policy Number: 76 SBU BM6KBA ._. Additional Information: —]KooT e:___:] Next Gen tryp Spectrum Dear Nathan John, January 16, 2025 El Contact Us Visit htt s.d/business.thehartford.com 24/7 access to pay bills, view policy documents, get your certificate of insurance and more. Need Help? Chat online or call us at (888) 925-3137. We're here Monday - Friday. Thank you on behalf of NUTMEG INS AGENCY INC/PHS and The Hartford for allowing us to serve your business insurance needs. The Certificate of Insurance and Endorsement Forms that you have requested are attached. If you have any questions, please contact us Monday through Friday from 8am-8pm (ET). Sincerely, Carlisle Carter Agency Services Phone: 1-866-467-8730 Fax: 1-877-905-0457 Email: agengy.services@thehartford.com cc: NUTMEG INS AGENCY INC/PHS / 76210797 BlkLtrPol THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. THE HARTFORD ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following BUSINESS LIABILITY COVERAGE FORM Except as otherwise stated in this endorsement, the terms and conditions of the Policy apply. A. The following is added to Section C. WHO IS AN INSURED: Designated Person Or Organization a. The person(s) or organization(s) shown in the Declarations as Additional Insured — Designated Person Or Organization is also an additional insured, but only with respect to liability for "bodily injury", "property damage" 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: (1) In the performance of your ongoing operations; or (2) In connection with your premises owned by or rented to you. b. If coverage provided to these additional insureds is required by a written contract or written agreement, or when required by a written permit issued by a state or governmental agency or subdivision or political subdivision, the insurance afforded to these additional insureds will not be broader than that which you are required by the contract, agreement, or permit to provide for these additional insureds. c. The insurance afforded to these additional insureds only applies to the extent permitted by law. B. With respect to the insurance afforded such additional insured(s) by this endorsement, the following additional exclusion is added to Section B. EXCLUSIONS: This insurance does not apply to "bodily injury" or "property damage" included within the "products -completed operations hazard". Form SL 30 42 10 18 Page 1 of 1 © 2018, The Hartford (May include copyrighted material of Insurance Services Office, Inc., with its permission) ilk t�11111 I I 1 11 The document you requested showing proof of insurance for Account #XXXXXXXXX193813 Nathan John DBA Kweku Abimbola is attached. Please contact LIS if You have any questions or concerns. Thank you for selecting The Hartford for your business insurance needs. Sincerely, The Hartford Services Team arjyaLy,,Ep s of li—s@ I Lqatagt 115- 1 1 Agg--'ni L . r Lkp4i�. IgrXI gLi This email was sent to: jLkjL2-3Mbtg-= Attached: CERTIFICATE OF INSURANCE (COI).Pdf You'll require Adobe® Reader in order to open PDF attachments. Qpyyja�ggs,) a free Adobe® Reader to your computer This email was sent by: The Hartford. 3600 Wiseman Blvd. San Antonio, TX 78251, United States 0 2025. All Rights Reserved. This is a customer service message from The Hartford. For security reasons, we kindly ask that you do not reply to this email. If you have questions regarding your account, please contact us or log in so we can properly verify your identity. For Arizona, California, New Hampshire, Texas and Washington, your (or the) specific insurance underwriting company can be easily obtained by viewing the insurance policy document accessed through the link as specified above. THE HARTFORD BUSINESS SERVICE CENTER THE 3600 WISEMAN BLVD HARTFORD SAN ANTONIO TX 78251 City of El Segundo 350 MAIN ST EL SEGUNDO CA 90245-3813 Account Information: ........ Policy Holder Details : Nathan John DBA Kweku Abimbola January 16, 2025 Ll Contact Us Need Help? Chat online or call us at (866) 467-8730. We're here Monday - Friday. Enclosed please find a Certificate Of Insurance for the above referenced Policyholder. Please contact us if you have any questions or concerns. Sincerely, Your Hartford Service Team WLTRO05 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 Policy Number Expiration Date Name of Agent Phone # �) 1 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. 1 /21 /25 Signature of Applicant Date Nathan Kweku John Print Name Agreement for: Dated. Reviewed by: