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PROOF OF INSURANCE (2026 - 2026)COVERAGES CERTIFICATE NUMBER: A-SP-SU-25-01-06-327552 REV151UN NU L5t:K: . . .................. . .... — 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 INSR LM . ..... . TYPE OF INSURANCE __EENERAL —LIABILITY ............ . ADM 14SR-JUVO, . SUBR . . . ......... . . . ..... . . ....... . . . ......... . . ...... . . . . . POUCYEFF POLICY EDP ...... LIMITS EACH OCCURRENCE A N N S0019GL000001-04 01/06/2025 01106/2026 FIRE DAMAGE TO PREMISES X COMMERCIAL GENERAL LIABILITY REN,Tf� (APY1199e0famisoeSL $ 300.000.00 CLAIMS -MADE OCCUR EK I MED EXP (any --person) $5,000-00 - ------------- - INCLUDES ATHLETIC PARTICIPANTS X PER & ADV INJURY s 1,000,00q�,9,0 . . . . ................... ----------- I$ �ENERAJL AGGREGATE 3,000,OOQ.00 - - I ........... 1. - - - ------------------ GENERAL AGGREGATE LIMIT APPLIES PER:. C S-COM P/ GG 6016 PROD.... $ 2,000 . . .. ..... . . . . ....................... —, " 0 , 0 " 0 ", 0 - 0 POLICY F1 PROJECT LOC ............ . . $ ........ . .......... AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO HIRED AUTOS I I 1 ­­­11 11 ------ - ------------- -1.1. I'll, I ­ - - ------------- H_ BODILY INJURY (Per person) $ ALL OWNEDNON-OWNED -,""I'll" . . . . .. .. .. ............ .. . ­1. 1­1 111­ - --------- ----------- BODI­1 LY INJURY (Per accident) Is AUTOS AUTOS 1 11.1 — ------------------ ---------------- PROPERTY DAMAGE SCHEDULED AUTOS (Per accident) .......... 1 $ . ....... ... ... ...... . ... UMBRELLA L F OCCUR EACH OCCURRENCE $ ........ . ... ..-------- - ... ....X. EXCESS LIAB CLAIMS -MADE E EGATE AG G R $ . ............ $ DEDUCTIBLE . ................ . ........... _ RETENTION A ........ WDRI(ERSOOMPENSATION .......... . WOSTATUH TQRYUAHTS..... .Eke.._ . .. . . .............. .... ANDWLL4BLrrY ANY PROPRJETORPARTNEREXECUTIVE M OFF10ERMEMBEREXCLUDED? EL EACH ACCIDENT (MandEftyinNH) NIA If yes, describe under SPECIAL PROVISIONS below , FA EMPLOYEE $ . ....... _LL..aILEASE E L. DISEASE - POLICY LIMIT 5 . . ............... A Abuse/Molestation N N S0019GL000001-04 01/06/2025 01/06/2026 Each Occurrence: $ 100.000 00 Aggregate: $ 500,000 00 DESCRIPTION ................ . ............ . . . OF OPERATIONS I LOCATIONS I VEHICLES . ........... (Attach ACORD 101, Additional Remarks Schedule, if more space is required) . . . ..................... . . Liability Policy Deductible: $0,00 Deductible for Bodily Injury and $ 1000,00 per Property Damage Claim, ISO Occurrence form CG 00 01 04 13 and company's specific forms. Coverage for Participant Legal Liability requires that every participant signs a waiver/release, RE: Registered Drama participants: 01/06/2025 - 01/06/2026; . ................... CERTIFICATE HOLDER ........................... CANCELLATION . .... ..... ....... . ...... ............ City of El Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main Street AUTHORIZED REPRESENTATIVE El Segundo, CA, 90245 -;, Mark Di Perno ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD @1988-2009 ACORD CORPORATION. All rights reserved. ©2008 ACORD CORPORATION. All rights reserved. ACORD 101 (2008101) The ACORD name and logo are registered marks of ACORD Get your digital proof of insurance & membership card on the AAA App *Download the ap o Click AAA.ccim/app75 Electronic proof of eum mcs.Y molr ont W 44 eon prow m ol: 14,ako hard copy «esron on hard Must be a anent AAA member one irKuled lfwtoarlPa,9/G t"a «a'm.G YYYat¢ariar� Aiodfrti4rkt 4Pu ii'fXxuo«r+ar'rdYrg4,mt,b,mawn9� to AnfkoM'' Menage: NO and foaming roles may ^tier -InCainsurance Ec hangs of the Automobile --�-- Insurance Club l ��s NAIC k. 15598 i X Named Insured Policy Number: CAA073654962 X GODINEZ i Effective Date: 08/31/2025 Expiration Date: 08/31/2026 X q, This policy complies with Sections 16056 or 16500.5 of the California ti Vehicle Code. Coverage subject to policy terms and limits. « r --- ------ VEHICLES ON POLICY YEAR MAKE 2012 FORD ESCAPE XLT 2005 FORD FOCUS SW ZXW w 2 W S o DRIVERS ON POLICY O LL GODINEZ. SAMUEL PAUL Nona I.D. M ---_-_--..._-_-,-----..------------------.,........------------__-----.»..-.._..,-----------...._,..._----------------------------- IF YOU HAVE AN ACCIDENT CALL OUR 24/7 AAA CLAIMS HOTLINE 1-800-672-5246 I W After an accident, exchange information with the other party and I follow these 5 easy steps: r p « q Step 1: Pull vehicle over to a safe place. Get the names, addresses. Step 4: Take photos of the vehicles involved, damages and and phone numbers of all persons involved in the accident, e.g.. ,;, surrounding area of the accident, if it is safe to do so. a pedestrians, witnesses. other passengers, etc. w = Step 5: Call our AAA Claims Hotline at 800-672.5246 to report the I' e Step 2: Take photos of or write down the other person's driver's J loss. If necessary, we will arrange to'have your vehicle towed, Our p i license information and other vehicle's license plate number, a provider's tow trucks always display the AAA emblem. r including state of registration. i Do not admit responsibility for or discuss the circumstances of the accident Step 3: Take photos of or write down the other person's insurance with anyone other than the police or an authorized Auto Club claims w X card information. representative. Do not disclose your policy limits to anyone. " I For questions or changes to your policy, call 1-877-422-2100. Monday through Friday from 7 a. m. to 9 p.m. or Saturday from 8 a. m. to 5 p m. -..__r--,----------..---------------,-----»....------..__----.....,.....,-----....,.,.,---------.....__----------..---------„----------- Evidence of financial responsibility shall at all times be carried in the vehicle. In addition, we suggest that each listed driver carry a. card. Under California law, drivers and owners of a motor vehXcle must be able to Call our AAA Claims show proof of financial responsibdlity at all fumes, Insurance informiation has already, been submitted Hotline at 1-800-672-5246 directly to the DMV electronically, submit this document to DMV only it specifically requested by DlMV.. Those cards become invalid and shotlld be del royed on the expiration or lerminatkln date of the policy. r----_----,----..,----.._.._-__------....-------------------....-----_--------..,--,.-----_------_--------- _-------,-------� California Evidence of Liability Insurance VEHICLES ON POLICY , Interinsurance Exchange of the Automobile Club , NAIC k: 15598 X Y 1 p Named Insured Policy Number: CAA073654962 MW « w � X l t 4 r t k 1 � M Effective Date: 08/31/2025 Expiration Date: 08/31/2026 X u This policy complies with Sections 16056 or 16500.5 of the California Vehicle Code. Coverage subject to policy terms and limits. r f i IF VOI 114AVF aN Arrlr)FNT Il L. MIR After an accident, exchange information with the other party and w follow these 5 easy steps: « X Step 1: Pull vehicle over to a safe place. Get the names, addresses. r and phone numbers of all persons involved in the accident, e.g., t pedestrians, witnesses, other passengers, etc. a Step 2: Take photos of or write down the other person's driver's "i license information and other vehicle's license plate number, L including state of registration - Step 3: Take photos of or write down the other person's insurance card information. YEAR MAKE VEH I.D. IA 2012 FORD ESCAPE XLT X 2005 FORD FOCUS SW ZXW ; Y X X d r f X DRIVERS ON POLICY r r r X OODINEZ, SAMUEL PAUL «' 1 110m r X r ,row.«...-......«..,.w.w.rwww.«..rw.w.n......,...-......----aw.«,w;rr...........................w....--.r....,----.,n rl.... Y 24/7 AAA CLAIMS HOTLINE 1-800-672-5246 i r Step 4: Take photos of the vehicles involved, damages and surrounding area of the accident, i1 it is safe to do so. p i r Step 5: Call our AAA Claims Hotline at 800-672-5246 to report the 1 loss. If necessary, we will arrange to have your vehicle towed. Our w provider's tow trucks always display the AAA emblem. o a « Do not admit responsibility for or discuss the circumstances of the accident with anyone other than the police or an authorized Auto Club claims n representative. Do not disclose your policy limits to anyone. i For questions or changes to your policy. call 1-877-422-2100, Monday through Friday from 7 a.m. to 9 p.m. or Saturday from 8 a, m. to 5 p.m. q, X X...,.--.-.-._.--,----.........-�..»...,--.--..--.-..-.--.----'-..--.,,,,,.„........«.«..,,..»......._.____--,.......---...«...»_.__---,........-,...-........._.-__-�-�-.-,-__-..--...,.....w�__-_----�..._....--.. ----I LRc6POIX"a All i 11Y311 Ynm vn 1. 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: So 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. C&O 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 # 80 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 1 must immediately comply with those provisions or the agreement will automatically become void. Signature of Applicant Date 05n3/2025 Print Name Samuel Godinez Agreement for: Dated: Reviewed by: