PROOF OF INSURANCE (2025) CLOSEDlwsuwnxcc rouwAxtrs
Great American Alliance Insurance Company
301 E.. Fourth Street, 25 S
Cincinnati, OH 45202-4201
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(844) 520-6991
Powered by Veracity Insurance Solutions, LLC
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 PLF197543
CERTIFICATE HOLDER: AMELIA MAYA cache fashions custom jewelry CERTIFICATE NUMBER:
ADDRESS: 10887 valley drive, RIVERSIDE, California 92505 AA332972
POLICY PERIOD: 11 /20/2024 to 11 /20/2025 12 01 A M, Standard Time at the Address or The Certificate 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
TYPE OF BUSINESS: Sole Proprietor/Individual
BUSINESS DESERIPTION.. Jewelry
PREMIUM:
TOTAL POLICY COST: (The cost is 100% earned/non refundable)
$169.00
$169.00
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 DETAIL OF ANY INCIDENT SHOULD BE SUBMITTED VIA THE CUSTOMER DASHBOARD. QUESTIONS CAN BE SENT VIA EMAIL
TO VERACITY INSURANCE SOLUTI0 d _ C INJ I H S tD WEST SUITE 303, PLEASANT G# OVE, 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: -
.yf�p ADMINISTRATED BY
Veracity Insurance Solutions, LLC
260 South 2500 West Suite 303
- Pleasant Grove Utah 84062
(844) 520-6991
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:
(A� 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. PLF197543
(A� 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 Great American Alliance Insurance Company Policy Number Expiration Date 11/20/2025
Name of Agent Powered by Veracity Insurance Salutlans, LLC Phone # ®44 520,6901
C 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 l 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 na19n19ms
Print Name Am 1'a
Agreement for:
Dated:
Reviewed by: