PROOF OF INSURANCE (2025)0 DATE (MM/DD/YYYY)
A40V CERTIFICATE OF LIABILITY INSURANCE
06I23I2025
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 have ADDITIONAL INSURED provisions or 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 CONTACT Tanner Thompson
NAME:
PHONE FAk
Jaffe Insurance Agency A/C (310) 827-5050 AIC No . (310 ) 827-6060
13160 Mindanao Way #204 ADDRESS: Tanner@jaffeinsurance.com
AFFORDING COVERAGE
Marina del Rey CA 90292 INSURERA: HIsCOX Ins Co
INSURED INSURER B :
Marty Felgen INSURER C :
3312 Tilden Ave INSURER D :
INSURER E :
NAIC #
Los Angeles CA 90034
1 INSURER F :
COVERAGES
CERTIFICATE
NUMBER: CL2562313889
REVISION NUMBER:
THIS
IS TO CERTIFY THATTHE 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.
NSR
POLICY'EFF
''.
POLICY ERP
.�....�.-..m.W_
LIMITS
LTR
TYPE OF INSURANCE
INSO
YV1/
POLICY NUMBER
MMIDDIYYVY
W
X COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE $ 1,000,000
"'` Gt �- 100,000
CLAIMS -MADE � OCCUR
Pe
REMISES dFa awr.:.narq�awrtio $
.........
MED EXP (Any one person) $ 5,000
A
Y
Y
P100.812.306.4
12/21/2024
12/21/2025
PERSONALBADVINJURY $ 1,000,000
................ ..
GEN'L AGGREGATE LIMITAPPLIES PER
GENERAL AGGREGATE $ 2,000000
✓'"4, POLICY JET LOG
El
PRODUCTS - COMP/OP AGG $ S(T Gen. Agg.
.....
OTHER:
COMB'NNEID SINGLELIMIT $
AUTOMOBILE LIABILITY
Aaacc ie_4a....... „,
ANYAUTO
BODILY INJURY (Per person) $
. OWNED SCHEDULED
_ BODILY INJURY (Per accident) $
AUTOS ONLY AUTOS
HIRED NON -OWNED
_PROPIERTY DAMAGE $
AUTOS ONLY AUTOS ONLY
Per acEwenl
$
UMBRELLA LIAB OCCUR
EACH OCCURRENCE $
EXCESS LIAB CLAIMS -MADE
AGGREGATE S
DED RETENTION $
......... $
WORKERS COMPENSATION
PER OTH-
STATUTE
AND EMPLOYERS' LIABILITY Y / N
„ER
ANY
E.L. EACH ACCIDENT
OFFICER/MEMBER ER EXCLUDED?
0
N / A
N/A
(Mandatory in NH)
E.L. DISEASE - EA EMPLOYEE
$
Ir yes, describe under
DESCRIPTION OF OPERATIONS below
_.
E. L;,DISEASE - POLICY LIMIT
$
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is,required)
The City of El Segundo, its officers, officials, employees, agents, and volunteers are included as Additional Insured as respects to the operations of the
Named In
sured per written contract.
CERTIFICATE HOLDER
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
The City of El Segundo ACCORDANCE WITH THE POLICY PROVISIONS.
350 Main St.
AUTHORIZED REPRESENTATIVE
ElSegundo CA 90245
@ 1988-2015 ACORD CORPOKAI IUNI. All ngnts reservea.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
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.
(_) 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
Signature of Applicant p agreement will automatically become void.
immediately complywith those provisions or th Date 5/27/25
Print Name Martin Felclen
Agreement for:
Dated:
Reviewed by: