PROOF OF INSURANCE (2025) CLOSEDCERTIFICATE OF LIABILITY INSURANCE DATE(MMmDreYrvl
�'. O6/OS/2025
THIS CERTIFICATE IS ISSUED As 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).
PRODUCER cORTA
NAAME,: FLIP Program Sup;wt -.... _..... ...
Veracity Insurance Solutions, LLC. FAX
Rook plop (844)-1520 6g9�T
260 South 2500 West, Suite 303 E alre(o tIlPToi)aarat r:om
Pleasant Grove LIT 84062 RRSURERtSp AFFORDING COVERAGE NArc A
W UAc Ar GraalAmerican AlffarnCeinsuranCeC„r, 26832
INSURED
RWSUREA B' ,
Shar Lee, DBA Wok and Grill BBQ WSURER C
3730 Collis Avenue INSURER D., _
Los Angeles CA 90032 IN'SURfn L.-
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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LRR ........ TYPE OF INSURANCE EA'Cai+O W`c"LfAtREawCO'i _
UNITS
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GENERAL UABILlTY G
IX COMMERCIAL a.EMERkALLIABIL"Y axu.n r�a,r 1 3tI4�"�
CLAIMS -MADE C. k
A i PLF194992-F270550 09128/2024 09/28r2025 pok ONAL,r&AW INJURY t, 1,000,000
calruaAo-�IleFrxxc m 2,0000001
GEayadAGGREGATE
^Yg�pnI,VREGIELuMAJMTAPPI.rSPEt PRODUCTS Cu1or raeu$ 2,000,.0_0,.0
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yPJ YC4 lyvnta
_ ANY AOJYfJ V. 0DRY0PdJl RY(Pea Erg so ) 5..
ALL. OWNED SCHEDULED
AU' BODILY INJURY (U a arstdam4) $
hIOiM1P OYNYJFfk r�F1a a -I'd Ia retE"7A'hZApi7"
HIRED AUTOS ..... AUTOS ,..It' ......_ ......
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UMBRELLA LIAB OCCUR I EAC UI OCCURRENCE $
EXCESS LUIB f, NA7C,t"x ltAel•1 199I1 AGGRE.GATr 8
r1EO Rr'IENT7f)N$ $ —
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VYORNERS COMPEWSATION
wvt,srraor,I taH-
' AND EMPLOYERS' LUIBWN Y/ N rr fdW LIpms Lw$._.,
ANY PROPRIERTNER/EXECUTIVE EL EACH ACCIDENT b
OFPICEafl/LAEMBEXCEXCLUDED? ❑ N / A
(Mand®ry In NH)
NHI EL DISEASE- ..EA6%a'A 4kxk'.E $
II pas describ9 undF
DESCRIPTUDINOF nP n c E DMEASE CrOLICY ILiMiT £
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, 11 more space is "ulred)
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)
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
The City Of El Segundo, its officials, employees, agents and volunteers ACCORDANCE WITH THE POLICY PROVISIONS.
300 Main Street
El Segundo, CA 90245 AUTHORIZED REPRESENTATIVE
ACORD CORPORATION. All rights reserved
ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
INS025 (201401)
PLF194992-F270550
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, its officials, employees, agents and volunteers
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
CG 20 26 (Ed. 04 13)
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, 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. 04113) 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
(_) 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 #
(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 subje;��agreeme
rkers co ensa'tion provisions of Labor Code § 3700 1 must
immediately comply with those illl automatically become void. �
Signature of Appl
Print Name
Agreement for:
Dated,
Reviewed by:
Date