PROOF OF INSURANCE (2026)A DDIYYYY)
CERTIFICATE OF LIABILITY INSURANCE 06/25/2025
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE. LISTED BELOW HAVE BEEN ISSUED TO fl E 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..
TN,S_R
DUI'
UBR
NUMBER
POLICY EFF
POLICY EXP
LIMITS
LTD
TYPE OF INSURANCE
INSD
VD
POLICY
(MM/DD/YYYY)
(MM/DD/YYYY)
EACH OCCURRENCE
$1,000,000
X 'COMMERCIAL GENERAL LIABILITY
DAMAGE TO RENTED
$50.000
CLAIMS MADE OCCUR
PREMISES (Ea occurrence)
ED EXP (Any one person)
$5,000
q
'. X
CSG-00321641-00
09/0112025
09/01l2026
ERSONAL $ ADV INJURY
$1,000,000
I
GENERAL AGGREGATE
$2,000,000
taEk1 L AGGREGATE LIMIT APPLIES PER:
X POLICY PROJECT LOC
PRODUCTS - COMP/OP
$2 000,000
AGG
Other:
COMBINED SINGLE LIMIT
AUTOMOBILE
LIABILITY:
KEa accident)
ODILY INJURY (Per
erson)
$
ANY AUTO
ODILY INJURY (Per
OWNED AUTOS ONLY SCHEDULED AUTOS
HIRED AUTOS ONLY NON -OWNED AUTOS
ccident)
$
® ONLY
PROPERTY DAMAGE(Per
$
ccident)
UMBRELLA LIAB
I
OCCUR
ACH OCCURENCE
$
EXCESS LIAB
CLAIMS -MADE
GGREGATE
$
DED
RETENTIONS $
ORKERS COMPENSATION
weuv,w,r:.^vaaoL >a.mnw
E.L. EACH ACCIDENT
,$
AND EMPLOYERS' LIABILITY
tL DISEASE - EA
$
ANY PROPIETOR/PARTNER/EXECUTIVE Y/N
OFFICE/MEMBER EXCLUDER? El
EMPLOYEE
(Mandatory in NH)
E,L„ DISEASE -POLICY
If yes, describe under
DESCRIPTION OF OPERATIONS below
LIMIT
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
224 W Oak Ave
El Segundo, CA 90245
Certificate holder is named as an additional insured, coverage is primary $ non-contributory and a waiver of subrogation applies as per written contract with the first named insured.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
PROOF OF COVERAGE ACCORDANCE WITH THE POLICY PROVISIONS„
AUTHORIZED REPRESENTATIVE
David McFarland
ACORD 25 12016031 The ACORD name and logo are registered marks of ACORD O 1988.2015 ACORD CORPORATION. All rights reserved.
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
y comply urovisions or the agreement will automatically become void.
immediately c I with th se
Signature of Applicant P Date 8/26/2025
Print Name Tyler th-Kovall
Agreement for:
Dated:
Reviewed by: