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PROOF OF INSURANCE (2025 - 2026)C y gDATE IYYYY)L — r �' ACIII CERTIFICATE OF LIABILITY INSURANCE o2/28/202a/zo25 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE 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 have ADDITIONAL INSURED provisions or be endorsed. 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 endorsements . PRODUCER CONTACT .,.._.. .. ... . ............ .•.•.• Next First Insurance Agency, Inc. F PHONE (855) 222 5919 P :.$'t� Ext3 - """ . _/tifC NtloE: PO Box 60787 Palo Alto, CA 94306 .Lt E MAIL su ort@nextinsurance com PNMA&" PP _ . AF) F'OR.DLIi COVERAGE _............. NAIC . INSURI" w...._.__�. INSURERA: State National Insurance Company Inc ............ 12831 INSURED INSURERB.' .................... -. .............. ......... ----- Naomi Go] DBA The City of El Segundo INSURER C 350 Main St �..__ .... _ ......_-- m_ El Segundo, CA 90245 INyISU ER-9 ...-. ... ............. . ..........------- �. RER E ., .w----- INSURER F VERAGES CERTIFICATE NUMBER: 018383565 REVISION NUMBER: CO 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. ....._.. TYPE ILT �.. OF INSURANCE POLICY NUMBER POLICY I�FF M YYY P6'L�RCY FKP MMQD' YYY '..... LIMITS EACH OCCURRENCE $1,000,000.00 ------ X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE � OCCUR I�-T�f� ER hd SES E vaC,urryncxp) $100,000.00 MED,FJCP (Any one person) $10,000,00 A X NXTA44WFQC-03-GL 09/01/2024 09/01/2025 PERSONAL&ADVINJURY $1000,000.00 GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE ,GENE ................ $3 000 000.00 -------.......,.. X POLICY ❑ JEO.'r LOC JECT PRO .._........AGG DUCTS COMP/OP AGG $3 000 000 00 - ----0- OTHER: COVI/,FINED SINGLE LIMIT $ AUTOMOBILE LIABILITY „(,I ,a, KJOSE�,,,,,,,,,,,,,,- -----„ '.. ANY AUTO BODILY INJURY (Per person) ....... .............. $ ............... . _. '.OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS ONLY ,,,, AUTOS HIRED NON -OWNED fiOPERTY DAWI GE ......®®®° -'�"' ... $ AUTOS ONLY AUTOS ONLY ier acCTdes�IS •••• . °-------- $ UMBRELLALIAB OCCUR EACH OCCURRENCE $ ..---- EXCESS LIAB CLApIb1S-IbtADE ..._. AGGREGATE _.. . $ .. ...........,.,...-...-,.........,...-...,�. _._......, OED RETENTION $ _ $ WORKERS COMPENSATION STATUTE... ERH ....._.... _ _..... -- AND EMPLOYERS'LIABILITY YIN .......... E.L. EACH ACCIDENT ANY'PROPRNE'1°OMPARTNEPJEXIrCLITVVE. ❑ OFFICEFVMEMBF..R EXCLUDEOt (Mandatory In NH) N / A E.L.. DISEASE EA EMPLOYEE $ ff 4yes, das robe under DESCRIPTION OF OPE'IA"I"IONS aelo E.L. DISEASE -POLICY LIMIT $ Each Occurrence: $1,000,000.00 A Professional Liability NXTA44WFQC-03-GL 09/01/2024 09/01/2025 Aggregate: $3,000,000.00 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORDI101, Additional Remarks Schedule, may be attached if more space Is required) The Certificate Holder is City of Ell Se �rundo, its elected and appointed officials, employees, and volunteers. This Certificate Holder, its elected and appointed officials,. employees, and volunteers is. an Additiona)'Insured on the General Liability policy on a primary and non-contributory basis. NEXT will endeavor to provide this Certificate Holder if required by written Holder with written notice of cancellation 30 days in advance for any of the following pohcles; General Liability All Certificate privileges apply only agreement between the Certificate Holder and the insured, and are subject to policy terms and conditions. ,TE HOLDER ty of Ell Segundo, its elected and appointed officials, n loyees„ and volunteers 0 Main St. Segundo, CA 90245 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD " a DATE (MM/DDNYYY) CERTIFICATE OF LIABILITY INSURANCE 02/24/2025 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE 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 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). PRODUCER Nep,e,PACT OVldlu BOlun Pacific First Insurance Services 79734 Parkway Esplanade N La Quinta , CA 92253 INSURED Naomi Gol 1619 S SHENANDOAH ST Los Angeles, CA 90035 - .-. FAX 5750 ........... ,_ to NCI , ....800 989. sut),Dort(a,aocontractcr incur nce.com Redwood Fire and Casualty Insurance Company f 11673 INSURER B INSURER C INSURER D INSURER E : I — A— 4)1r"tiPNtIAW IUIIMRFR• 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. ... _.-.-.., �.�..... ,.. _ fSn1wn ...................-. .„......MMIDD..„..I'MMdOD!"I'YYY..J...........,.,,... .. ...... ........". .....•� "O u... POLICY EFF POLICY EXP LIMITS INTR POLICYMUMBER...,_. I TYPE OFINSURANCE........ COMMERCIAL OMMERCIALGENERAL°� I EACH OCCURRENCE $ „ CLAIMS-MADE X-°LIABILITY _ OCCUR ! DAMAhEi'Yi" (.._PRF{NI$SS„(,Sa_ �L.. ._... _.. 08/24/2025 I $ R PERSONALAB ADV INJURY J $ GEN'LAGGREGATE LIMIT APPLIES PER: "GENERAL AGGREGATE. , ...... $ .._............. ............,... ........... POLICY l LOC POLICY a PRODUCTS -AGG $ ... ....� u JEOT , ..., ... $ OTHERI SINGLE LIMIT � $ Oo AUTOMOBILE E LIABILITY ICOMBINED rMJIURY(Per I ANY AUTO BODILY person) .B _. .. ........,. $ ............. .. ,,,, _..... .,......, ALL OWNED SCHEDULED f i _ 01APM05588101 02/25/2025 02/25/2026 BODILY INJU RY (Per accident) $ A Autos I_ HIRED AUTOS I ... AUTOS i _ t ( DAMAGE ...... ... $ --- i i $ UMBRELLA LIAR OCCUR UMBRE..., EACH OCCURRENCE . E" " $ „ EXCESS LIAR E r J. OLAIMS MAD.... AGGREGATE ... I... ..._ $ .._. .... ..,...... DED RETENTION $ I $ WORKERS COMPENSATION - X l STA U OTH E EF AND EMPLOYERS' LIABILITY YdN ACCIDENT E L EACH A ,. $"„",,,,",." ANY PR PRIETOR/PARTNER/EXECUTIVE N / A l OFFICER/MEMBER EXCLUDED? . ....... "" LOYEE $ (Mandatory m NH ) ( ry IF yes, describe under ( i .... POLICY LIMIT ... $ DESCRIPTION OF OPERATIONS below I E L DISEASE 1 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) ERTIFICATE HOLDER CANCE City of El Segundo [ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 350 Main Street Itt THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN El Segundo , CA 90245-3895 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE © 1988-2014 AORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD 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 ($100NE'l IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS ` FOR IN LABOR CODE § 3706, INTEREST, AND ATTORNEY" S- I affirm under penalty of perjury under the laws of California one allowing declarations: (L 1 have and will maaintain a certificate of consent Pinsure for workers' compensation, issued by the Director of Industrial Relations as provided for by Labor e § 3700 for the performance of the work set forth the agreement with undo. Policy No. (� 1 have and will ethe n workers' compensation insurance as required by Lam of the work for greement with the City of El Segundo is executed. My carrier and y number are: Policy Number Expiration Date c D• O 1 3700 forthe performance cation insurance 0 of Agent ([l� I certify that, in the performance of the work set forth in the agreement with the City of El Segundo, I , not employ any person in any manner so as to become subject to the workers' compensation laws of Califomia, d agree that, if I should become subject to the workers' compensation provisions of Labor Code § 3700 1 mu. immediately comply with those provisions or tqe agreement will automatically become void. # Date Signature of Applicant —211 w o� Print Name Agreement for. Dated: Reviewed by