PROOF OF INSURANCE (2025) CLOSED"4" wNzi d"e'.Ntl S
Great American Alliance Insurance Company
301 E,. Fourth Street, 25 S
Cincinnati, OH 45202-4201
ACT
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INSURANCE
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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 PLF108324
CERTIFICATE HOLDER: Brandy Markovich
CERTIFICATE NUMBER:
ADDRESS: 8115 Redlands St 106, Playa Del Rey, California 90293 AS352457
POLICY PERIOD: 05/02/2025 to 05/04/2025 12'01 A M Standard Time at the Address of The Cerlfcate Holder
LIMITS OF INSURANCE
General Aggregate Limit (Other than Products -Completed Operations)
$
2,000,000
Products -Completed Operations Aggregate Limit
$
EXCLUDED
Personal and Advertising Injury Limit
S
EXCLUDED
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
TYPE OF BUSINESS: Sole Proprietor/Individual
BUSINESS DESCRIPTION: , Art; Crafts Jewelry
PREMIUM:
TOTAL POLICY COST: (The cost is 100% earned/non refundable)
$10.00
$10.00
CODE NUMBER: 63217 PREMIUM BASIS: Number of Days EXPOSURE: 1 - 3 Consecutive Days
CLASSIFICATION: Art, Crafts, 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 CLA11§@M92JN_S_Q)_M OR BYTO VERACITY INSURANCE SOLUTIONS., L 26o SOUTH 2500 WE TILE SUN E 303, PLEASANT GROVE. UT 84062.
.._.._..............m
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:
ADMINISTRATED BY
Veracity Insurance Solutions, LLC
260 South 2500 west Suite 303
Pleasant Grave Utah 84062
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(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:
(_) I have and will maintain a certificate of consent of self -insure for workers' compensation, issued by the Director
of Industrial Relations as rovided 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 Cod§ 3700 for the performance
of the work for which the agreement with the City of El Segundo is executed. My workers' compensation insurance
Carrier Policy Number Expiration Date
Name of Agent Phone #
QL) 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 workers' compensation provisions of Labor Code § 3700 1 must
immediately comply with tho wis s or the agreement will automatically become void. 03/31 /2025
Signature of Applicant Date
Print Name Cra��d Niarlcovi
Agreement for:
Dated:
Reviewed by: