PROOF OF INSURANCE (2025) CLOSED8'48 .,.!,
IBL-PKGPD8HKJC 2002 - Done
Policy Info Coverage & Limits
Policy Number IBL-PKGPD8HKJC
Category Vendors (Not Selling Food or Beverages)
Crew Size Just Me
Policy Effective Date 05/03/2512:00 AM PDT
Policy End Date 05/03/2511 59 PM PDT
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SIGNATURE PAGE
In Witness Whereof, we have caused this policy to be executed and attested, and, if required by stale law,
this policy shall not bevalidunless countersigned by our authorized representative.
.._._.........._...�siignahue.................... -----------.
(signature)
Secretary President
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 workers' compensation provisions of Labor Code § 3700 1 must
Signature of Applicant ��"'`ment will automatically become void.Ll
provisions r t e a ee ,^
immediate) complywith those r Date
Print Name
Agreement for:
Dated:
Reviewed by: