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PROOF OF INSURANCE (2025) CLOSEDDATE (MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 04/01/2025 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 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). PHONE (] ...... �. Ve®h Insurance Inc. e31b� 322-1626 j;� No31a0 322 3547 C NIACr NAf 302 W. Grand Ave #8 E-MAIL "... El Segundo, CA 90245 APPrRF,, 5 m debble(C verC lnsurance Com .. ER 5 AFFORDING COVERAGE NAIC # U.� Com ay n............... ) 524210 ...._...._..........................5�...L......L.ns..u..rance INSURER A p. — �. —......_—..............................................._...._........................................... INSURED INSURER B. Create and Express INSURER C : _ ... 405 Main St _______ ........ El Segundo, CA 90245 IrvsuRER D _., a 6.,.., INSURER E ; INSURER F : COVERAGES CERTIFICATE NUMBER': REVISION NUMBER: 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. w-�.... INTO .... POLICY E�1� f POLIOY CXP LIMRS.. '`fW ..� ...��. - TYPE OF INSURANCE POLICY NUMBER MOLIC .:._Y"�mmmpJYYYY GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 yahnav� tt "kL1 300,000 W� COMMERCIAL GENERAL LIABILITY PRFMISES (Ea occurrence} 5 CLAIMS -MADE ®occuR CP26$8970 }( 8/29/24 !08/29/25 MEDrso ExP(Anyanepeny s 5,000 A PERSO � NAL S ADV INJURY s 1,000,000 !I GENERAL AGGREGATE $ .___ ..._... 2,000,000 .... _.. OLN'l. .......... AFE .... ...... ....... " .LIMIT APPMES PER: -- PRODUCTS COMB OP AGG $ 1,000,000 POLICY _..,. PRO. ..._._LOC ' S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO BODILY INJURY (Per person) "(Per S .....r.r �.�..�. ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED BODILY INJURY accident) .... ._ rPROPERTY DAMAVE � S —. S ...� HIRED AUTO AUTOS ...�.�.. 5 UMBRELLA LIAB w . OCCUR EACH OCCURRENCE S .— EXCESS LIAR .CLAIMS -MADE _...,.,..... ... i AGGREGATE DEDRETENTIONS S WORKERS COMPENSATION WC STATlJ- OTH AND EMPLOYERS' LIABILITY ANY PROPRIE OR/PARTNERIEXECUTIVE — EACHACCIDENT OFFICERIMEMBER EXCLUDED? inE.L (Mandatory NH)DISEASE,- N I A . EMPLOYEE ...S,,,,,,,,,,,,, ..........., If yes, describe under DESCRIPTION OF OPERATIONS below E.L.. DISEASE -POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) Event date May 3, 2025 The city of El Segundo its officers, employees, agents and volunteers are additional insured. City Of El Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 350 Main St THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN El Segundo, CA 90245 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE P&bo-ra-, La.d-�-Parry © 1988-2010 ACORD CORPORATION. All rlgnts reservea. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD 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 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 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 Ic tl°ie workers' compensation provisions of Labor Code § 3700 1 must Signature comp lth those p�roui ion s or e agreement will autornatically become void. g g C�.. gate w, v Print Name M 2"` Agreement for: Dated: Reviewed by: