PROOF OF INSURANCE (2026)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:
LX_) 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. 90-GK-A943-1
(_X) 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 State Farm
Name of Agent Jessie Pierce
Policy Number Expiration Date 6115125
Phone # 512-326-4630
(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 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 5/8/25
Jonathan Muzacz
Print Name
Agreement for:
Dated:.
Reviewed by: