PROOF OF INSURANCE (2025)TE
14 CERTIFICATE OF LIABILITY INSURANCE DA03/13/20D25YI
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 Soaap0ul1d Program Suppon
Veracity Insurance Solutions,LLC� k ,Old/ V,644•52 •6989 'Ax Nov 374
260 South 2500 West, Suite 303 E-MAIL 4nt $oa urfrUnsumnce com
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Pleasant Grove UT 84062 INSURER($,) AFFORDING COVERAGE NAIC o
INSURER A' Great American Alliance Insurance Company 26832
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INSURED INSURER B : _.
Sean Olson INSURER C
15571 Producer Ln Unit l
Huntington Beach CA 92649 INSURER F ,
COVERAGES CERTIFICATE NUMBER: KtvlSlOn NI mtStlC:
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.
I�kTRR TYPE OF INSURANCE ,. aeaR.tDgp. POLICY NUMBER fAMrOOk)LrCffYYY FF Pi1kRG"Yy ........ UMITS ....... ...
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,. GENERALAGGREGATE �.S 1 000,000
AGGREGATE LIMIIr!¢RTIL!k..S FIER:
AUTOMOBILE LIABILITY
ANYAUY0
A' A. OWNED
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HIRED AUTOS
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WORKERS COMPENSATION
AND EMPLOtlERT OABILmY
ANY PROPRIETOR)PAITNERtEXECUTIVE YIN
OFFICEfMEMBER EXCLUDED? (_ N / A
IMantla(erg lU NH)
IIves, tlescriba under
PRODUCTS ' COMPK) r AGO ._..S
S 1.000.000
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.-ANIMAL BAILEE
C4:7I,1G.EUNED SVW(:.I...:. I..0 4 .
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DESCRIPTION OF OPERA'nONS l LOCATIONS t VEHICLESAUat, s Schedule, ACORD 101Additonal Remark T-_,........ .
(UI®, if mare 3 is required)
OeAificale holder has been added as addilional insured regarding the above mentioned policy per a@ached Additional Insured — Designated Person or
Organization (CG 20 26 Ed.. 04 11)
The City of EI Segundo its officers, officials, employees, agents and
volunteers
350 Main Street
El Segundo, CA 90245
MC.Lfl„NA.1 MW'R'M
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORRED REPRESENTATIVE
9�
0 1998-2014 ACORD CORPORATION. All rights rese
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
INS025 (209409)
PLF 197508-HSCGO38091
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED — DESIGNATED PERSON OR ORGANIZATION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
Schedule
Name of Additional Insured Person(s) or Organization(s):
The City of El Segundo its officers, officials, employees, agents and volunteers
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
CG 20 26 (Ed. 04 13)
A. SECTION 11 - WHO IS AN INSURED is amended to include as an Additional Insured the person(s) or
organization(s) shown in the Schedule, 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.
However:
1. the insurance afforded to such additional insured only applies to the extent permitted by law; and
2. if coverage provided to the Additional Insured is required by a contract or agreement, the insurance afforded to
such additional insured will not be broader than that which you are required by the contract or agreement to
provide for such additional insured.
B. With respect to the insurance afforded to these Additional Insureds, the following is added to SECTION III —
LIMITS OF INSURANCE:
If coverage provided to the Additional Insured is required by a contract or agreement, the most we will pay on
behalf of the Additional Insured is the amount of insurance:
1. required by the contract or agreement; or
2. available under the applicable Limits of Insurance shown in the Declarations;
whichever is less.
This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations.
Copyright, ISO Properties, Inc., 2012
CG 20 26 (Ed. 04113) PRO Page 1 of 1
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 ATTORNEYS 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
Name of Agent
Policy Number Expiration Date
Phone #
X
I certify that, in the performance of the work set forth in the agreement with the City of EI Segundo, I will not
oy 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 p_Coyisions or the agreement will automatically become void,. 3 ,
Signature of Applicant
C
Print Name
Agreement for:
Dated,
Reviewed by:
Date --�''