PROOF OF INSURANCE (2025) CLOSEDA...,.. DATE (MMIDDY(YY)...
CERTIFICATE OF LIABILITY INSURANCE I25r2212125
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 cerloficate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed,. Il' SUBROGATION IS WAIVED, subyvct to the
terms and conditions of the policy, certain policies may require on endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s),
PRODUCER NAME FLIP Program Support
Veracity Insurance Solutions, LLG I4pIjp,exat„(fi4q� 2 60(I2 AX,NP}. _
260 South 2500 West, Suite 303 °MIL info@rliprogram,rwrm
Pleasant Grove UT 64062 1 INSURER(S) AFFORDING COVERAGE "Ma
INSURED
Karola Flores, DBA La Lemonade
4466 W 135Th St A
Hawthorne CA 90250
wwsuNER' ro: Great American AIIiarx8 Insurance Co. 2)6632
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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
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PERSONAL &AT8v4N,..IUR, s 1,000,000
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DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Anach ACORD 10" Addiftnal Remarks Schedule. it mare space is required)
............°m. ..........
Certificate holder had been added as additional insured regarding the above mentioned policy per attached
Additional Insured - Designated Person or Organization (CG 20 26 Ed. 04 13)
CERTIFICATE: HOLDER
CAN (.B,LLA i Kj N
ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
7TACCORDANCE
XPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
The City Of EI Segundo
WITH THE POLICY PROVISIONS„
350 Main St.
El Segundo, CA 90245
AUTHOR— REPRESENTATNE
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
INS025 (201401)
PLF046122-F259713
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 PART
Schedule
Name of Additional Insured Person(s) or Organization(s):
The City of El Segundo
M
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
CG 20 26 (Ed. 04 13)
A. SECTION 11 - WHO IS AN INSURED is amended to include as an Additional Insured the person(s) or
organization(s) shown in the Schedule, but only with respect to liability for "bodily injury," "property damage" or
"personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of
those acting on your behalf:
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.
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.
Copyright, ISO Properties, Inc., 2012
CG 20 26 (Ed. 04/13) PRO Page 1 of 1
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:
(J 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.
U 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 #
00 1 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 autOfTlatically become void. 5122/2025
Signature of Applicant Karola Flores Date
Karola Flores
Print Name
Agreement for: La Lemonade
Dated:
Reviewed by:
Special Event — Hold Harmless & Indemnification
La Lemonade
CONTRACTOR:
DATE: 05/22/2025
INDEMNIFICATION. Seller agrees to indemnify and hold City harmless from and against any claim, action, damages, costs (including, without limitation,
attorney's fees), injuries, or liabirty, arising out of the Purchase or the order, or their performance. Should City be named in any suit, or should any claim be
brought against it by suit or otherwise, whether the same be groundless or not, arising out of their product and/or performance, Seller will defend City (at
Citys request and with counsel sat factory to City) and indemnify City for anyjudgment rendered against tl or any sums paid out in settlement or otherwise.
For purposes of this secticn "City' includes Cit)/s officers, elected officials, and employees. It is expressly understood and agreed that the foregoing
provisions will survive termination of this order. The requirements as to the types and limits of insurance coverage to be maintained by Seller, and any
approval of such insurance by City, are not intended to and will not in any manner limit or qualify the liabilities and obligations otherwise assumed by Seller
pursuant to this order, including, without limitation, to the provisions concerning indemnification.
Below you will find a list relating to Insurance and other requirements that are required for doing business with the City of El Segundo. These
items are MANDATORY. Policies will be endorsed to name the City, its officials, and employees as "additional insureds" under said insurance
coverage and to state that such insurance will be deemed "primary" such that any other insurance that may be carried by the City will be excess
thereto. Such insurance must be on an "occurrence," not a "claims made," basis and will not be cancelable or subject to reduction except upon
thirty (30) days prior written notice to the City.
't orkers" Comoensatiom Insurance: as required by State Statutes. (Not needed if Self-employed 'ith no employees and CONTRACTOR signs
statement to this effect.) If you have no employees please sign here to certify fMM
PLEASE NOTE: ALL APPLICABLE INFORMATION LISTED ABOVE MUST BE OBTAINED AND ON FILE„ PRIOR TO,
THUS AUTHORIZING COMMENCEMENT OF WORK FOR THE CITY.
Company Name:
By (Print name & title):
La Lemonade
Karola Flores — Owner
Company Street Address:
Vendor's Aulh , Y ignature required:
4466 W. 135th St. Apt. A
��
City, State, Zip:
Date signed:
Hawthorne, CA 90250
1 05/22/2025
I
Phone:
FAX:
310 593 ,1392
N/A
Vendor's Email address:
Vendor's Web site:
If you have any questions, please call Andrew Booras at 310-524-2700 or
abooras@elsegundo.org
(1) Special Event Hold Harmless WC only (6) 10/15/21