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PROOF OF INSURANCE (2026)"a',. DATE (MM/DD/YYYY) A OR CERTIFICATE OF LIABILITY INSURANCE 07/09/202S 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 CONTACr I FAX PHONE PO Box 60787 t� ..... aney Next First Insurance Agency, Inc, � AEAIL (855) 222 591 (AdS� �., kxisl, 9 Palo Alto, CA 94306 AOORESS. iaf . aarrlanaa:.rrarwu wVN§UR-R(_S)AFFORDING COVERAGE ......._-.. i ,...�....� State National Insurance Company, Inc. I 7831 INSURED INSURER B : Indian Summer Grill 958 Main Street INSURER C, El Segundo, CA 90245 INSURER D INSURER E : r'AVFR6r;FS CERTIFICATE NUMBER:427478345 REVISION NUIVIt3EK: A 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. -' - .... ...... ,' 4bbL SUPP - ,.,POLICY EPF POLICY E% >• ;R ( (,�w'� POLICY NUMBER MMIODP^rYYY MMNwYO i''W'YYY LIMITS INSURANCE LIABILITY EACH OCCURRENCE ( 51 00 I00 00 COMMERCIAL DccuR UAMAU TO HCki 60 -.. Xr $100 000 00 LAIMMADEERAL .m wr _L X ., .P EWSES ( i t-ouw ®, .- X IX INXTDWHL3WJ-00-GL GPNIL AGGREGATE LIMIT APPLIES PER: _X_ I POLICY ECT I LOC AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED ,._...., AUTOS ONLY AUTOS HIRED NON -OWNED _.I AUTOS ONLY __,,,, AUTOS ONLY UMBRELLA LIAR 991 ,OCCUR EXCESS LIAR I Ci Ainea WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y I N ANYPROPRI ETOR/PARTNER/EXECUTIVE OFFICERIMEMBEREXCLUDED? ,NIA (Mandatory in NH) l IF yes, describe under DFSnRIPTION OF OPERATIONS below MED EXP (Any one person) 1 $10 000 00.... 07/09/2025 �07/09/2026 PERSONAL & ADV INJURY ... $1,000,000.00 G ENERALA $..... 1,000,000.00 RODUCTSGGREGA7E -COMP/OP AGG d $1.000 000 00 OMBpNPI7 SINGLE LIMIT $ � taow. deA0./ ��_ _ BODILY INJURYns (Per person) BODILY INJURY (Per accident) PROP LRaYDA,�tAGL,... $ .. ,.-. _..... 09L as.r^kWiq,j. L E ACH OCCURRENCE 1 $ AGGREGATE ...._. , .�, r$ .. .... - 4$ E L EACH ACCIDENT 4 $ E.L. DISEASE EArMPLOYEE° $ E.L. DISEASE -POLICY LIMIT r $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) The Certr kake Holder is Ei Segundo Parks & Recreation, A WaiVer of Stataroga' tlnil applies in favor cal this Cwtlficate Holder an Ifie frallowing polwcles Generat Liability. '[Phis C`er dficata Holder Is an Additional Insured on the Geraer�al LiaWRt ptalmy on a 0mary and non•Coltaralattt:ory basIs Thrs Cer0li„ate Holder us an Additional Insured on the Generral l.Ialailit policy with res aert to on mole m o'rerarior 1'da"rs d �Trclficate N°la�der, is an Additional insaared on tllie, General LObility pro-l`Icy yullla a°e5pert lIa r°orla(1leter1 ol:re ations. General Liability coverage a ples for Resraurarn¢loperaations In Caltforwa. All Certificate Holder pr Iwilege. apply curly' it regiArcd by written agroer°ncrrt betw,tKnn the Certificate Holder ;and trite. insured, ar�wct arts. SUbjeer to policy terrns and condivorm CERTIFICATE HOLDER CANCELLATION I SegLwprdo llJrks IC Recreation LIVE CERT IFICATE ndlan surnmo Grill SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 139 Sheldon St THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN _I Segundo, CA 90245 ) ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Glckor scan „tD-view ©1988-2015 ACORD CORPORATION. All rights reserved. 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: (_) 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.. L) 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 # C_) 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 e agreement will automatically become void, 7 -5- Signature of Applicant '' .µ Date Print Name 4 Ate. Agreement for: Dated:. Reviewed by: