PROOF OF INSURANCE (2026)ACORD 25 (2010/05)
CCDATE (MM/DDIYYYY)
'Mk� CERTIFICATE OF LIABILITY INSURANCE 06/17/2025
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 Afohin llnnnori-,i In—irnn Inr NAMM5.r. AFSHIN KANGARL„Ott ........
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. ...........POLICYNUMBER .... m..,.,r—POLICY ELF PCA,h..t"CY�F`iCP ...........r..... ... ..,,,....
_ ,.,. -----'— 1, MM.(DD dYYYY.
INSR TYPE OF INSURANCE �A SR# SUBft I LIMITS
GENERAL LIABILITY
���
EACH OCCURRENCE
$ 1
C .
x COMMERCIAL GENERAL LIABILITY
oNaEbecµui
300000
ll $
310 000
E x i OCCUR
.,, �
MAD......
92-E8-P142-9
04/01/2025
' 04/01/2026
_ n y one person)
Is 10 000
PERSONAL 8 ADV INJU RY
.._
I$ T 000,000
........ ......-......._
.... -CLAIMS
,�... _.........
.... ....
GENERALAGGREGATE
000 000
$$
. GEL AGGREGATE LIMIT APPLIES PER:
oAGG
$ 2000 000
?
BC
POLICY LOC
o
PPai
12800x]
A
AUTOMOBILE LIABILITY
�U
.
�
�
COMBINED SINGLE 69M1 '
�
X I ANY AUTO
681 9051-618-75
02/18I2025
BODILY INJURY (Per person)
BODILY
OB/18 2025
$ 30,000
. - -
ALL OWNED SCHEDULED
... ,.
I ODILY INJURY (Per accident)
$ 60,000
AUTOS----,m,
kfly
Imt kdenIAL
v
25 000
X... HIRED AUTOS AUTOSWNED
""
.....
1
es
Deductibles
$ 500
UMBRELLA LIAB OCCUR[30
�,
EACH OCCURRENCE $
EXCESS,LIAB CLAIMS MADE
�
AGGREGATE $
DED RETENTION $
$
WORKERS COMPENSATION
( WC STA TU OTH-i
I TI,�RY LIMITS IE
AND EMPLOYERS' LIABILITY
ANY PROPRIETORIPARTNER/EXECUTIVE YIN
...
` EL EACH ACCIDENT $
OFFICE/MEMBER EXCLUDED') NIA
L�i
--- """ "" "" ,, -
(Mandatory in NH)
I-E_L DISEASE EA EMPLOYE $ _
If yes, describe under
POLICY LIMIT 1 $
E.L.10
QFSDISEASE
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
• Workers compensation is not applicable as there are no employees.
• SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL
MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAME
Location: Stevenson baseball field Recreation park 408 eucalyptus dr, el Segundo, ca 9245
CERTIFICATE HOLDER
THE CITY OF EL SEGUNDO, ITS OFFICERS, OFFICIALS,
EMPLOYEES, AGENTS, AND VOLUNTEERS
408 Eucalyptus Dr
El Segundo, CA 90245
.(Q�Gd v G.iL2C.bd
1988-2010 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD 1001486 132849.8 01-23-2013
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
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 #
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 I must
immediately comply with those provisions or the agreement will automatically become void.
Signature of Applicant r°' Date 6117125
Print Name Magda navarro
Agreement for:
Dated:
Reviewed by: