PROOF OF INSURANCE (2026)Farmers Market: Hold Harmless, Release & Indemnification
In consideration of being permitted to participate in the City of El Segundo Farmers Market,
Travis DeRose ("Vendor") agrees to the following:
1. Vendor agrees and represents that it inspected, or immediately upon entering public property will inspect,
the premises, equipment, and facilities used for the Farmers Market. Vendor finds and accepts them as
being safe and reasonably suited for the purposes of Vendor's participation in the Farmers Market.
2. Vendor understands that Farmers Market activities may result in significant personal injuries, including
death. Vendor releases, waives, discharges, and covenants not to sue the City of El Segundo, its elected
and appointed officials, agents, volunteers, and employees (collectively, "Releasees") from all liability to
me, for any loss or damage, and any claim or demands on account of personal or property or death,
whether caused by Releasees' negligence or otherwise, while Vendor participates in the Farmers Market
(including, without limitation vehicular travel to and from the Farmers Market location).
3. To the fullest extent of the law„ Vendor agrees to indemnify, release, and hold City Releasees harmless from and
against any claim, action, damages, costs (including, without limitation, attorney fees), injuries, or liability, arising
out of Vendor's participation„ acts, or omissions, at the City's Farmers Market ("Vendor's Activities"). Should any
City Releasee be named in any suit, or' should any claim be brought against it by suit or otherwise, whether the
same be groundless or not, arising out. Vendor's Activities, Vendor will defend City Releasee (at City's request
and with counsel satisfactory to City) and indemnify City Releasee(s) for any judgment rendered against it or any
sums paid out in settlement or otherwise.
4. Vendor expressly agrees that this agreement is intended to be as broad and inclusive as is permitted by
the law of the State of California and that if any portion is held invalid, it is agreed that the balance shall,
notwithstanding, continue in full legal force and effect.
5. The signatory below represents that they have the legal authority to enter this agreement and bind Vendor
accordingly.
Comnanv or Sole PronriPtor's Name: By (Print name P. titlel:Travis DeRose
Travis DeRose
Vendor Street Address: 612 E. Queen St. #5 Vendor's Authorized Sionature: /
City, State, Zip: Inglewood, CA 90301 Date signed: 8/15/2025
Phone: (714) 328-9699 Vendor's email address: travderose@gmail.com
RETURN COMPLETED FORM TO:
RECREATION & PARKS DEPARTMENT
ATTN:
401 SHELDON STREET
EL SEGUNDO, CA 90245
If you have any questions, please call Linnea Palmer at 310-524-2882.
2/24/25
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 #
() 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 manger 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 p,ra isions or the agreement will automatically become void.
Signature of Applicant �°"` Date 'iztize
Print Name Travis DeRose
Agreement for:
Dated.
Reviewed by: