PROOF OF INSURANCE (2026)u
DATE
SPECIALTY CERTIFICATE OF LIABILIW INSURANCE (MM/DDNYYY)
103/13/2025
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 endorsement(s).
Specialty Insurance Agency
Vendors of the U.S.
3432 Denmark Ave N231
Eagan, MN 55123
Tiffany's House Inc.
c% Katy Yeh
210 West Grand Avenue, Apt F
Alhambra, CA 91801
Contact Name: Heather Weiss Zenzen
Phone: 715-246-8908 FAX: 715-246-8908
Email: carts@specialtyinsuranceagency.com
INSURERS AFFORDING COVERAGE I NAIL fi
INSURERA: Evanston Insurance Company 35378
INSURER B:
INSURER C:
INSURER D:
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. AGGREGATE
LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
TYPE OF INSURANCE ADDL Shea POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION
LIMITS
INSD WVD OATE(MM/DDrM DATE(MM/DD
DX,OMMEACIAL GENERAL
EACH OCCURRENCE
$ 1 ,000,000
4AOIL11'Y
DAMAGE TO RENTED
$ 300,000
CLAIM'S MADE�CCUR
PREMISES (Ea occurrence)
MED E%P (A^Y one Pe =n )
$ 5,000
A
GEN'LAGGREGATE LIMIT
X
X
2CN0182-1039
03/01/2025
03/01 /2026 12:01 am
PERSONAL & ADV INJURY
$ 1.000.000
APPLIES PER:
GENERAL AGGREGATE
$ 2,000.000
X POUCY PROJECT
PRODUCTS -COMP/OP
s2,000,000
LOG
AGG
A
BUSINESS PERSONAL
AGGREGATE
$
PROPERTY -INLAND MARINE
SEXUAL ABUSE AND
EACH OCCURRENCE
$
A
MOLESTATION
AGGREGATE
$
OCCUR
A
DATA BREACH AND CYBER
AGGREGATE
$
LIABILITY COVERAGE
A
EQUIPMENT LEASED OR
AGGREGATE
$
RENTED
UMBRELLA LAB
EACH OCCURRENCE
''.$
EXCESS LIAB
OCCUR („Ud"ckpg$.-MADE:
AGGREGATE
$
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS
VENDOR IS A NAMED INSURED AS A MEMBER OF VENDORS OF THE U.S.:
Tiffany's House Inc. c/o Katy Yeh
Additional Insured: The City of El Segundo, its officers, officials, employees, agents and certified volunteers are named as additional insured, but only insofar as
the operations under this contract are concerned.
Email: rdelgado@elsegundo.org Attn: Ryan Delgado Event Dates: 05/03/2025 - 05/03/2025 Includes Setup And Teardown
Insured for sales of: Handmade jewelry. Permanent storefront exclusion applies. Coverage territory does NOT extend to
NYC and the five boroughs.
CON -ffl1ffq-1Nf 4 111501 WIWI.
ril (yrOR44.1wellllrr1iMI
City gUn
CI Of El Segundo
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
350 Main Street, Room 5
BEFORE THE EXPIRATION DATE THEREOF, THE INSURER AFFORDING
COVERAGE WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE
El Segundo, CA 90245-3813
CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO
SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE
INSURER, ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
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 #
& 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 work rs' compensation provisions of Labor Code § 3700 l must
immediately comply with th ,se royis s or he agr;meat will automatically become void.
Signature of
Print Name
Agreement for:
Dated:
Reviewed by:
Date 2L1 )1