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PROOF OF INSURANCE (2025 - 2026)4CCERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) S�M � 04/22/2025 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 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). PRODUCER CONTACT Will Maddux East Main Street Insurance Services, Inc. PHONE (530) 477 6521AAx,. tl) ...... E MAdL, er com Will Maddux -.-_9 $ s ei y Grass Valle CA 95945 INSURER A . Evanston Insurance Cc ERAGE { 35378 nlc Ire D eeven p PO Box 1298 INSURER( y INSURED INRURFR R . David Lee Kitchen INSURER D 15545 Gundry Ave INSURER E Paramount CA 90723 INSURERF: nnv�o wnoo r+•cpsYocrrwnTo r.uuenoo. RFVICIflIJ NIIMRFR 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. f ..�.w.e..�,.,..w ,TYPEOFINSURANCE """" .... ,.�� .... .POLICY... ............ ....r. ........... ....... ........... ....... ........ EkP [ ILTR ,. ._.._ SObL I.vD NUMBER � MMIDDDNYYYI lMM/flCN YY MMl'17D1YYY 4 - LIMITS ( COMMERCIAL GENERAL LIABILITY I ACH OCCURRENCE EAlNAO(= $ 1,000,000 1 CLAIMS -MADE OCCUR f(i iiC=N1 �i7 pRIEMIRES�. (other than fire) � $ 1 000 00.0 ............... .. Host Liquor Liability 111 M EXP (Any one person) $ 5,000 .... A ,.. I Retail Liquor Liability Y N 3DS5476 M4729523 04/30/2025 05/01 /2025 PERSONAL a AD..INJu Y $ 1 000,000 .. . _. .."... ... i APPLIes PER. 1 EN'L AGGR 12:01 AM ........ED l 12:01 AM GENERALAGGREGATE $ 2 O00 000 �GATEJE+r LCMC POLICY1 ' C PRODUCTS - AGG 11 """ 1 000 OOO _l Ded UCh bleCOMP/OP $ ,000 AUTOMOBILE LIABILITY J ' COMBINED SINGLE. LVfufYT $ )U _ ANY AUTO j RY URY (Per person) f $ INJU OWNED SCHEDULED y , INJURY (Per accident) $ AUTOS ONLY ....� AUTOS J w.. HIRED N BODILY i{,Pr R7„W,YA4AGL $ - -ecewdont AUTOS ONLY i ---- AUTOS ONLDY a.r ,,, ...: UMBRELLA LIAB OCCUR I EACH OCCURRENCE I s ................... ......................... EXCESS LIAB 1 CLAIMS -MADE I AGGREGATE . DED 1 RETENTION$ i $ WORKERS COMPENSATION p H 1..,—,. SIf.A.TUTE �d._ R L AND EMPLOYERS' IABILITY YIN ,�� ....... ................... .__ ..........,. MBE PARTNER/EXECUTIVE N/A .L EACH ACCIDENT .......__ .... $....... .. FER/MANYPROPR OFFICER/MEMBER ❑ ' Q 1 EDISEASE EAEMPLOYEFI( II $____ (Mandatory in NH) ) If describe under .L " yes, DESCRIPTION OF OPERATIONS below , E,.L.. DISEASE POLICY LIMIT I $ I DESCRIPTION OF OPERATIONS/LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) Certificate holder listed below is named as additional insured per attached MEGL 2217 01 19. Attendance: 100, Event Type: Caterer, CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of El Segundo ACCORDANCE WITH THE POLICY PROVISIONS. its elected and appointed officials employees and Volunteers AUTHORIZED REPRESENTATIVE 350 Main St J//a/At�, 1 ElSegundo CA 90245 © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD COMMERCIAL GENERAL LIABILITY POLICY NUMBER: 3DS5476-M4729523 IRKEr EVANSTON INSURANCE COMPANY 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 FORM SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): City of El Segundo its elected and appointed officials employees and volunteers 350 Main St El Segundo, CA 90245 A. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule of this endorsement, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by the acts or omissions of any insured listed under Paragraph 1. or 2. of Section II — Who Is An Insured: 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. MEGL 2217 0119 Includes copyrighted material of Insurance Services Office, Inc., Page 1 of 2 with its permission. 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. All other terms and conditions remain unchanged. MEGL 2217 0119 Includes copyrighted material of Insurance Services Office, Inc., Page 2 of 2 with its permission. 03 e X ID Cards - 2025-03-28T151... Ok+ U STEPHANIE NELSON 1465 Henderson Ave Apt 4 Long Beach, CA 90813 45669 Company Infinity Insurance Company Policy Holder STEPHANIE NELSON Policy Number 10132412502 Effective 03/28/2025 Company Infinity Insurance Company Policy Holder STEPHANIE NELSON Policy Number 10132412502 Effective 03/28/2025 Company Infinity Insurance Company Policy Holder STEPHANIE NELSON Policy Number 10132412502 Effective 03/28/2025 1041DCD02 NAIC#22268 CALIFORNIA CALIFORNIA EVIDENCE OF LIABILITY INSURANCE Infinity Insurance Company 3760 River Run Drive Birmingham, AL, 35243 (800)782-1020 YEAR MAKE/MODEL VEHICLE ID NUMBER 2017 CHEVROLETNOLT POLICY NUMBER NAME & ADDRESS OF INSURED 10132412502 STEPHANIE NELSON 1485 Henderson Ave Ape 4 EFFECTIVE DATE Long Beach, CA 90813 03128/2025 EXPIRATION DATE DRIVER(S) STEPHANIE NELSON 09/28/2025 This policy complies with Sections 16056 or 16500.5 of the California Vehicle Code. CALIFORNIA INSUREDS THIS CALIFORNIA EVIDENCE OF LIABILITY INSURANCE CARD IS PROVIDED FOR YOUR USE TO ENABLE YOU TO COMPLY WITH SECTION 16056 OR 16500.5 OF THE CALIFORNIA VEHICLE CODE. SHOW THIS CARD TO THE REQUESTING PEACE OFFICER WHEN ASKED TO PROVIDE EVIDENCE OF LIABILITY INSURANCE. Evidence of financial responsibility shall at all times be carried in the vehicle. Insurance Information has already been submitted directly to the DMV electronically, submit this document to DMV only if specifically requested by DMV. IF YOU ARE INVOLVED IN AN ACCIDENT REPORT YOUR LOSS IMMEDIATELY PHONE: (800) 3KEMPER CALIFORNIA INSUREDS THIS CALIFORNIA EVIDENCE OF LIABILITY INSURANCE CARD IS PROVIDED FOR YOUR USE TO ENABLE YOU TO COMPLY WITH SECTION 16056 OR 16500.5 OF THE CALIFORNIA VEHICLE CODE. SHOW THIS CARD TO THE REQUESTING PEACE OFFICER WHEN ASKED TO PROVIDE EVIDENCE OF LIABILITY INSURANCE. Evidence of financial responsibility shall at all times be carried In the vehicle. Insurance Information has already been submitted directly to the 24-HOUR CLAIMS SERVICE (800) 3KEMPER IF YOU HAVE AN ACCIDENT. 1 OBTAIN THE NAMES, ADDRESSES, AND PHONE NUMBERS OF EVERYONE INVOLVED.. 2 RECORD THE DATE, TIME, AND PLACE OF THE ACCIDENT. 3. IDENTIFY THE OTHER DRIVER AND HIS/HER INSURANCE COMPANY. 4.. LIST THE MAKE, MODEL, AND LICENSE PLATE NUMBER OF THE OTHER HICLE. 5. PHONE THE P ICE AT ONCE. 6. PHONE US IMMEDIATELY, 24 HOURS A DAY, 7 DAYS A WEEK. MEMBER OF THE NAMONAL INSURANCE CRIME BUREAU 24.HOUR CLAIMS SERVICE (800)3KEMPER IF YOU HAVE AN ACCIDENT: 1. OBTAIN THE NAMES, ADDRESSES, AND PHONE NUMBERS OF EVERYONE INVOLVED. 000*WTE TIME, AND PLACE OF THE ACCIDENT. THE'.R DRIVER AND HIS/HER INSURANCE COMPANY. EMPLOYER' EMPLOYERS ASSURANCE CO. A Stock Company POLICY DECLARATIONS NCCI Carrier# 36870 WCIRB C 1. Named Insured and Address KITCHENS CORNER 15545 GUNDRY AVE PARAMOUNT CA 90723 Workers' Compensation and Employers Liability Insurance Policy Policy Number From olicy PeriodTo DWC 5962547 00L 04/30/2025 04/3012026 12,01A.KSlas rdi Time at tlklc a Mu1ue aBkhe In,ured �s =1 �eredn Transaction 00919 PRIOR POLICY NUMBER NEW Agent VERIFLY INSURANCE SERVICES INC 0003738 THIMBLE 174 W 4TH STREET SUITE 204 NEW YORK, NY 10014 Telephone: 3158701733 Customer # Carrier # FEIN # Risk ID # Entity of Insured 36870 991159477 LIM LIABILITY CO Additional Locations: 2. The Policy Period is from 04/30/2025 to 04/30/2026 12:01 a.m. Standard Time at the insured's mailing address. 3. A. Workers Compensation Insurance: Part ONE of the policy applies to the Workers Compensation Law of the states listed here: CA B. Employers Liability Insurance: Part TWO of the policy applies to work in each state listed in Item 3A. The limits of our liability under Part TWO are: Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 policy limit Bodily Injury by Disease $ 1,000,000 each employee C. Other States Insurance: Part THREE of the policy applies to the states, if any, listed here: All states except ND, OH, WA, WY and states listed in item 3.A. D. This policy includes these endorsements and schedules: See attached schedule. 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates, and Rating Plans. All information required below is subject to verification and change by audit. SEE EXTENSION OF INFORMATION PAGE Minimum Premium $ 750 Assessments and Taxes $ ❑ This is a Three Year Fixed Rate Policy Premium Adjustment Period: X Annual; Countersigned this Day of Issued Date: 04/22/2025 Issuing Office EMPLOYERS ASSURANCE CO. P.O. BOX 539003 HENDERSON, NV 89053-9003 Issued Date 04/22/2025 WC990630 (5/98 Ed.) Expense Constant $ 160 Premium Discount $ Total Estimated AnnualPremium $ 788 ❑ Semiannual; ❑ Quarterly; ❑ Monthly INSURED COPY Page 1 of 4 Authorized Representative