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PROOF OF INSURANCE (2025) CLOSEDA`' '"'? O6/, CERTIFICATE OF LIABILITY INSURANCE DATE 12/2025 2I25 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). PRODUCER RAME.: I FLIP Program Support Veracity Insurance Solutions, LLC, dANPHONE FAX Q844)-520-6992 IAIC, No);_ 260 South 2500 West, Suite 303 R info@Iliprogram.com Pleasant Grove UT 84062 INSURER(S) AFFORDING COVERAGE NAIC a MISURERA Great American Alliance Insurance Co, 26832 INSURED.. _ INSURER Koji Hashimoto, DBA Twist potato INSURER C: 1275 W. Capitol Dr. Unit 114 INSURER o: San Pedro CA 90732 INSURERE: 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. I S - `ADOL SUER _... POLACY FF PO Y' 7IP %»I' T'S TYPE OF INSURANCE POLICY NUMBER I4I GENERAL. LtABILM _ EACH OCCURRENCE S 1,000.000 `.� DAMAGE TO RENTED 300.000 COMMERCIAL GENERAL LIABILITY r"'-' I""` PREMISES (Ea ®ccurne w) „S CLAIIM&MADE X OCCUR $ I MIED EXP (Any one msonl s 5.000 A PLF046122-F263323 08/102024 08/102025 1,000.000 PERSONAL a ADv INJURY t GENERAL AGGREGATE . S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMPIOP AGO S'. 2,000,000 X..., POLICY '.. PRO, LOG ANIMAL BAILEEaccl , $ AUTOMOBILE LIABILITY roA.&N O!;"r,tNG"I;. I'II'e1R � tF amnw�or)wt®b "S ANY AUTO BODILY INJURY (Pee Perron) S ";,...,....: ALL OWNED SCHEDULED BODILY INJURY (Per a d-1) S ,.......... AUTOS AUTOS NON -OWNED ....PROPERTY DAMAGE HIREDAUTOS AUTOS (Pee.e dent) S UMBRELLA LIAR OCCUR I.:......^ I,.--_ EACH OCCURRENCE S EXCESS LWB-......., CLAIMS MADE. i AGGREGATE....... ...'$. I DED RETVIVON S _... _... , . WORKERS COMPENSATION WC STATU. OTH AND EMPLOYERS' LIABILITY TORY LIMITS ER ANY PROPRIETORIPARTNERIEXECUTIVE YIN p-- EACH ACCIDENT S I.I OFFICEEMBER EXCLUDED"+ NIA E L (Mandatory In NH) EA4PLOtlEE 5 II yes, descnbe under „ I E L DISEASE -POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101. Additional Remarks Schedule, d more space Is required) 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 CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of El Segundo ACCORDANCE WITH THE POLICY PROVISIONS. 314-348 Main st El Segundo, CA 90245 AUTHORIZED REPRESENTATIVE © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD INS025 (201401) 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 # (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 agreemett will automatically become void. Signature of Applicant Date ringigoor Print Name K Agreement for: Dated: Reviewed by: