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PROOF OF INSURANCE (2026 - 2026)143438 NMK Corporation Certificate Of Insurance 9/29/2025 1:26:42 PM DATE I /"wI . CERTIFICATE OF LIABILITY INSURANCE 9/29/2029/2025 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 Techlnsurance, Division of Specialty Program Group LLC 203 N. LaSalle St., 20th Floor, Chicago, IL 60601 INSURED NMK Corporation 2740 N Springfield St, Orange, CA, 92867 r ^%sca A.nCO f-r_0TI9:IrAIT K!"MM1R.PR: 688-1984 AFFORDING REVISION NUMBER: 312-690-4123 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. ..._..--�... IT...ITIT... ,... LIM.....,mm.p.. INSR .......... LTR, ITS TYPE..OF INSURANCE Y............. . ADDL SUBR.. ..... ... POLICY NUMBER....... PM DDYIYXYY M6, OpYPY "xY1P'' rr'7 COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 CLAMS -MADE ✓ OCCUR AWff N R cmp_)�... P-REMAI$ .... 1,000,000 .. .... MED EXP (Any one person) $ 10,000 B Yes 46SBMAW6SLF 9/25/2025 9/25/2026 PERSONAL & ADV INJURY $ 2,000.000 GEN L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 `7 POLICY PRO- LOC JE4 T PRODUCTS - COMP/OP AGG _ $4 000,000 _...... OTHER COMBINED SINGLE LIMIT $ 2,000,000 AUTOMOBILE LIABILITY aoc`rdent) ............._ ..... BODILY INJURY (Per person) $ ANY AUTO ....... ._......_�........... .- ALL OWNED SCHEDULED Yes 46SBMAW6SLF 9/25/2025 9/25/2026 BODILY INJURY (Per accident) $ ✓ ,AUTOS AUTOS PROPERTY DAMA_G '', ...... $ B HIRED AUTOS ✓-m, AUUTOSWNED .._...._ .... UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS -MADE AGGREGATE -...... $ DED RETENTION $ $ WORKERS COMPENSATION PER OTH- STATI.IT. ER AND EMPLOYERS' LIABILITY YIN ..... ANY PROPRIETOR/PARTNER/EXECUTIVE ..E.L. EACH ACCIDENT $ �...... ....._._ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) NIA E.L, DISEASE - EA EMPLOYE E.. DI—... $ If yes, describe under DESCRIPTION OF OPERATIONS below E L, DISEASE - POLICY LIMIT $ A Professional Liability (Errors and Omissions) 46TE0281457-25 10/17/2025 10/17/2026 Occurrence/Aggregate $2,000,000 1 $2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) The City of El Segundo, its officers, elected and appointed officials, employees, and volunteers as additional insureds. The City of El Segundo will receive thirty reduction. Coverage is and non-contributory such that any other insurance that may (30) days written notice in the event of cancellation, nonrenewed or primary be carried by the City of El Segundo will be excess thereto. C City of El Segundo 350 Main St El Segundo, CA 90245 CANCELLA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 4u--- ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD ENDORSEMENT NO:18 This endorsement, effective 12:01 am, 10/24/24 forms part of policy number 46 TE 0281457-24 issued to: NMK CORPORATION by: HARTFORD FIRE INSURANCE CO. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. FIRST PARTY EXPENSE ENDORSEMENT TH CYBER BREACH COACH NO RETENTION ION You and we agree that: The Limits of Liability stated in item 4 and the Retention Each Wrongful Act stated in item 5 of the Declarations Page are amended to add the following Limits of Insurance, Retentions, Waiting Periods, and Period of Restorations: First Party Aggregate Limit: $ , t9 0 000 First Party; 1-1ra±!9!3y rlesz rangy nizji r-4-iLy Expense Sublimits Retention Waitin Period. Crisis Management Expense $=109 $5,000 Cyber Investigation Expense $ . Q—O $5,000 Data Privacy Regulatory Expense $ $ Notification and Identity Protection Expense $ .000,000 $5�00. PCI Expense $N/A $N/A Cyber Extortion Expense $2.000 $5' Business Interruption Loss $N/A $N/A 0 hrs Dependent Business Interruption Loss $N/A $N/A 0 hrs Data Restoration Expense $N/A $N/A Period of Restoration Business Interruption Loss nt Business Interruption Loss 0 days 0 days The above First Party Aggregate Limit and First Party Sublimits are all sublimits of insurance that are part of, and not in addition to, the Aggregate Limit stated in item 4 of the Declarations. If the space for any of the above First Party Sublimits is left blank or indicated as "N/A", then there is no coverage for that First Party Expense. If the space for a First Party Retention is left blank or indicated as "N/A", the applicable First Party Retention will be the same as the Retention Each Wrongful Act stated in item 5 of the Declarations. If the space for a First Party Waiting Period is left blank, the applicable Waiting Period will be 12 hours. If the space for a Period of Restoration is left blank, the applicable Period of Restoration will be 30 days. Section I — Coverage, Subsection A. Insuring Agreement is amended to add: First party expenses elected below are subject to the applicable First Party Sublimit, the First Party Aggregate Limit and the Aggregate Limit stated in Item 4 of the Declarations, and are in excess of the applicable First Party Retention and Waiting Period. Where applicable, they are also subject to a period of restoration. The following first party expenses are provided if: (i) designated with an `X' hereon, FS 00 H610 00 0718 FailSafe Page 1 of 7 © 2018, The Hartford ENDORSEMENT NO: 18 (ii) a limit is specified for the applicable First Party Sublimit stated on page 1 of this endorsement, and (iii) you receive our prior written consent for such first party expenses: X] Crisis Management Expenses Coverage We will reimburse the named insured for crisis management expenses that directly result from a data privacy wrongful act or network intrusion. XI Cyber Investigation Expenses Coverage We will reimburse the named insured for cyber investigation expenses that directly result from a data privacy wrongful act or network intrusion. XJ Data Privacy Regulatory Expenses Coverage We will reimburse the named insured for data privacy regulatory expenses that directly result from a data privacy wrongful act. ❑X Notification and Identity Protection Expenses Coverage We will reimburse the named insured for notification and identity protection expenses that directly result from a data privacy wrongful act. ❑ PCI Expenses Coverage We will reimburse the named insured for pci expenses that the named insured becomes legally obligated to pay as a direct result of a data privacy wrongful act or network wrongful act. ❑X Cyber Extortion Expenses Coverage We will reimburse the named insured for cyber extortion expenses that directly result from a cyber extortion threat communicated to the named insured by a person or group, who is not insured under this policy. ❑ Business Interruption Loss Coverage We will reimburse the named insured amounts which the named insured incurs during the period of restoration as business interruption loss after the expiration of the Waiting Period, and extra expense, directly resulting from the named insured's network outage. ❑ Dependent Business Interruption Loss Coverage We will reimburse the named insured amounts which the named insured incurs during the period of restoration as dependent business interruption loss after the expiration of the Waiting Period, and extra expense, directly resulting from a third party service provider's network outage. ❑ Data Restoration Expense Coverage We will reimburse the named insured for data restoration expenses, as a direct result of the network intrusion. Named Insured: Santa Ana Unified School District, including their officials, officers, agents, and employees are named as additional insured on this policy. FS 00 H610 00 0718 FailSafe Page 2 of 7 © 2018, The Hartford ENDORSEMENT NO: 18 Section I — Coverage, Subsection C. When We Insure is amended to add: The coverage for first party expenses offered under this policy apply only if the following applicable terms are met: 1. the wrongful act is first discovered by a specified insured during the policy period and is reported to us in writing as soon as practicable from the discovery of the wrongful act by a specified insured but no later than ninety (90) days after the expiration of the policy period; 2. the cyber extortion threat or network outage first occurs during the policy period and is reported to us in writing by a specified insured as soon as practicable from the date the cyber extortion threat or network outage occurs but no later than ninety (90) days after the expiration of the policy period; 3. the network intrusion is discovered a specified insured during the policy period and is reported to us in writing by you as soon as practicable from the date the network intrusion is discovered but no later than ninety (90) days after the expiration of the policy period; and 4. prior to surrendering cyber extortion payments or the surrendering of property or other consideration as payment, the named insured conducts a reasonable investigation and reasonably determines that the threat is technologically credible. There is no coverage under this endorsement arising out of any data privacy wrongful acts, cyber extortion threats, network intrusions, network outages, or network wrongful acts occurring during any Extended Reporting Period offered under this policy. No Extended Reporting Period available to any of you shall apply to any first party expenses. None of you will, except at your own cost, make a payment, assume any obligation, or incur any cost without our consent, which will not be unreasonably withheld. The named insured shall obtain prior written approval from us prior to incurring first party expenses. However, you will not need prior written approval for the retention of any service provider on the panel of cyber first responders. All notices or correspondences regarding wrongful acts, cyber extortion threats, network intrusions, or network outages, must be sent to the address (es) or facsimile(s) indicated by endorsement to this policy. If a wrongful act, cyber extortion threat, network intrusion, or network outage occurs, you must: 1. immediately record the specifics of the wrongful act, cyber extortion threat, network intrusion, or network outage, and the date it occurred; 2. immediately send us copies of all applicable demands, notices, summonses and legal papers received in connection with the wrongful act, cyber extortion threat, network intrusion, or network outage; 3. authorize us to obtain records and other information; 4. cooperate with us in the investigation of the wrongful act, cyber extortion threat, network intrusion, or network outage; and 5. assist us, upon our request, in enforcing any right against any person or entity that may be liable to you for the first party expenses that may be applicable to this coverage endorsement. Section II — Definitions, is amended in the following manner: The following definitions in Section II — Definitions are deleted and replaced with the following: a business interruption loss means the sum of actual income loss and the named insured's continuing fixed operating and payroll expenses, resulting from a network outage of a named insured's computer system. business interruption loss does not include any contractual liability or the value of, or associated with, any cancelled contract, including but not limited to any sums due pursuant to a contractual provision for liquidated damages, agreed penalties, or similar remedy; 2. costs or expenses incurred to update, replace, restore, or improve the computer system; 3. costs or expenses incurred to identify or remediate vulnerabilities or errors in the computer system; FS 00 H610 00 0718 FailSafe Page 3 of 7 © 2018, The Hartford ENDORSEMENT NO: 18 4. damages; 5. claim expenses; 6. other first party expenses; or 7. amounts that are uninsurable pursuant to applicable law. • crisis management expenses means reasonable and necessary fees and expenses: 1. charged by a crisis management firm or cyber breach coach in the performance of crisis management services; and 2. for printing, advertising, mailing of materials, or travel by an executive officer, partner, owner, employee, agent of the named insured, or the crisis management firm as a direct response to a data privacy wrongful act or network intrusion. crisis management expenses do not include any of your overhead expenses or any salaries, wages, fees, or benefits of any you, nor do they include any amounts that are uninsurable pursuant to applicable law. • crisis management firm means any public relations or law firm hired or appointed by us or by you to perform crisis management services in connection with a data privacy wrongful act or network intrusion. ® crisis management services means those services performed by a crisis management firm or cyber breach coach to minimize potential harm to the named insured arising from a data privacy wrongful act or network intrusion, including: 1. maintaining and restoring public confidence in the named insured; 2. providing advice to the named insured in connection with such data privacy wrongful act or network intrusion; 3. determining the named insured's legal obligations under data privacy laws; 4. providing necessary legal services to the named insured in responding to a data privacy wrongful act or network intrusion; and 5. communicating prior to a claim or data privacy regulatory proceeding with regulators, consumers, and clients regarding a data privacy wrongful act or network intrusion. a cyber extortion payments means any actual, reasonable, and necessary monetary amounts, including amounts in bitcoin and cryptocurrencies, at the actual rate of exchange at the date and time of the transaction in the equivalent of United States of America dollars, paid by the named insured with our consent, not to be unreasonably withheld, to a party who is not insured under this policy and whom the named insured reasonably believes to be responsible for the cyber extortion threat if insurable pursuant to applicable law. Cyber extortion payments will also include any reasonable and necessary expenses incurred in order to facilitate, mitigate or negotiate any actual amount paid in response to the cyber extortion threat. m data restoration expenses means the actual, reasonable, and necessary expenses incurred by you to restore, replace or recover a computer program, software, application or other electronic data that is altered, destroyed, stolen, impaired or erased as a result of a network intrusion. If you determine that such computer program, software, application or other electronic data cannot be reasonably restored, replaced or recovered, then data restoration expenses means only the reasonable and necessary costs incurred by you to reach this determination. FS 00 H610 00 0718 FailSafe Page 4 of 7 © 2018, The Hartford ENDORSEMENT NO: 18 At our sole discretion, and subject to the our prior written consent which will not be unreasonably withheld, we may agree to reimburse the named insured for internal expense incurred to restore, remediate, replace, or recover a computer program, software, application or other electronic data. data restoration expenses do not include costs or expenses incurred to: 1. identify or remediate any errors or vulnerabilities or to update, restore, replace, upgrade, maintain, or improve any computer system; 2. duplicate the research that led to the development of the named insured's computer program, software, application, other electronic data or any proprietary or confidential information or intellectual property; or 3. develop or purchase any computer program, software, application or other electronic data. Nor do data restoration expenses include: a. the economic or market value of any computer system, computer program, software, application or other electronic data; b. any amounts that are uninsurable pursuant to applicable law; or c. any of your overhead expenses or any salaries, wages, fees, or benefits of any you. period of restoration means the period of time that begins with the date and time of the network outage and ends on the date and time the named insured's income is or could have been restored to substantially the level that would have existed in the absence of the network outage. The foregoing notwithstanding, in no event shall the period of restoration exceed the number of days set forth in the Declarations. The definition of cyber extortion threat in Section II. Definitions is amended to delete item 2. of the definition and replace with the following: alter, damage, encrypt, render inaccessible, or continue to render inaccessible any computer program, software or electronic data that is stored within the computer system including, but not limited to threats involving ransomware; Section II — Definitions is amended to add the following definitions: w breach coach services means the services described in sub -parts 3, 4, and 5 of the definition of "crisis management services" that are provided by a cyber breach coach. a cyber breach coach means a pre -approved law firm on the list of cyber first responders at the time notice of a data privacy wrongful act or network intrusion discovered by a specified insured during the policy period is tendered to us for coverage under crisis management expense coverage. r cyber first responder means a service provider approved by us to provide services related to the first party expenses in this Endorsement, and maintained in a periodically updated written list on The Hartford Cyber Center portal available at the following link http%L/cyberoent r..�hehartford.com • dependent business interruption loss means the sum of actual income loss and the named insured's continuing fixed operating and payroll expenses, resulting from a network outage of a third party service provider's computer system. Dependent business interruption loss does not include any: 1. contractual liability or the value of, or associated with, any cancelled contract, including but not limited to any sums due pursuant to a contractual provision for liquidated damages, agreed penalties, or similar remedy; 2. costs or expenses incurred to update, replace, restore, or improve the computer system; FS 00 H610 00 0718 FailSafe Page 5 of 7 © 2018, The Hartford ENDORSEMENT NO: 18 3. costs or expenses incurred to identify or remediate vulnerabilities or errors in the computer system; 4. damages; 5. claim expenses; 6. other first party expenses; or 7. amounts that are uninsurable pursuant to applicable law. internal expense means a named insured's overhead expenses, or any salaries, wages, or fees of its employees incurred as a result of a data privacy wrongful act or network intrusion of a named insured's computer system when the named insured undertakes all or a portion of the work to restore, replace or recover a computer program, software, application or other electronic data instead of hiring an external vendor. Provided, however, that, as a condition precedent to coverage, internal expense will only be recognized if: 1) the named insured performs such task(s) under the advice of a cyber first responder, 2) such expenses are specifically allocable to the data privacy wrongful act or network intrusion response, and 3) the named insured submits activity based accounting records in full support of such expense allocation. The definition of first party expenses in Section II. Definitions is amended to add the following: first party expenses also means dependent business interruption loss and internal expense. Section III — Exclusions, is amended in the following manner: Subsection A, item 2. is amended to add the following: This exclusion will also not apply to first party expenses covered hereunder as a result of the loss of the named insured's leased or owned computer hardware including mobile, networked, and data storage computing equipment; Subsection A., item 11. is amended to add the following: This exclusion will also not apply to first party expenses covered hereunder that the named insured pays as a direct result of a data privacy wrongful act; Section V — Limits of Liability and Retention, Subsection A. Limits of Liability is amended to add: 3. First Party Aggregate Limit Subject to A.2 of Section V — Limits of Liability and Retention, the First Party Aggregate Limit indicated in this endorsement is the most we will pay for the total of all first party expenses that apply to this policy, regardless of the number of: a. named insureds this policy covers; or b. wrongful acts, cyber extortion threats, network intrusions, or network outages that occur. The First Party Aggregate Limit is a sublimit of insurance that is part of, and not in addition to, the Aggregate Limit stated in item 4 of the Declarations. 4. First Party Sublimits Subject to A.2 and A.3 of Section V — Limits of Liability and Retention, the First Party Sublimit stated for each first party expense indicated in this endorsement is the most we will pay for each applicable first party expense, regardless of the number of: FS 00 H610 00 0718 FailSafe Page 6 of 7 © 2018, The Hartford ENDORSEMENT NO: 18 a. named insureds this policy covers; or b. wrongful acts, cyber extortion threats, network intrusions, or network outages that occur. The First Party Sublimits are all sublimits of insurance that are part of, and not in addition to, the First Party Aggregate Limit referenced in item 3 above and also the Aggregate Limit stated in item 4 of the Declarations. Further, any payment of Breach Coach Services by the Insurer will reduce the applicable Limits of Liability. Section V — Limits of Liability and Retention is amended to add: First Party Retentions The First Party Retention stated for each first party expense indicated in this endorsement is the amount of money the named insured must pay for each applicable covered first party expense arising from a wrongful act, cyber extortion threat, network intrusion, or network outage before this policy will begin to pay. You may not insure a First Party Retention. A First Party Retention will not be reduced by the payment of any deductible amount or any amount retained by any of you under any other policy of insurance; and a First Party Retention will not be reduced by any payment made on your behalf by another person or entity. A First Party Retention will not reduce the applicable First Party Sublimit orthe First Party Aggregate Limit. However, no retention will apply to the Breach Coach Services. If multiple first party expenses arise from the same wrongful act, network intrusion, cyber extortion threat or network outage, the retention for each applicable first party expense will be applied separately. However, with respect to all first party expenses other than Business Interruption Loss and Dependent Business Interruption Loss, the sum of such First Party Retentions shall not exceed the largest such applicable Retention. With respect to the Business Interruption Loss and Dependent Business Interruption Loss coverages of this policy, the applicable Waiting Periods will only apply to business interruption loss and dependent business interruption loss, but not to extra expense. The Business Interruption Loss and Dependent Business Interruption Loss Retentions will apply only to extra expense. In no event shall the sum of all applicable Retentions triggered by the same wrongful act, network intrusion, cyber extortion threat or network outage exceed the largest applicable Retention. All other terms and conditions remain unchanged. Douglas Elliot, President FS 00 H610 00 0718 FailSafe Page 7 of 7 © 2018, The Hartford ENDORSEMENT NO:19 This endorsement, effective 12:01 am, 10/24/24 forms part of policy number 46 TE 0281457-24 issued to: NMK CORPORATION by: HARTFORD FIRE INSURANCE CO. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. LIMITS OF LIABILITY CHA LGE. (INCREASE) In consideration of your payment of the additional premium of $2J Item 4. Limits of Liability of the Declarations is deleted and replaced with the following: 4. Limits of Liability Each Wrongful Act Limit $ ` �.0-0-- Aggregate Limit $ Q—OQ.. This endorsement will not apply to any claim made against any of you before 10/24/24; nor will it apply to any claim resulting from a wrongful act or circumstance known by any partner, executive officer, director or manager of the named insured prior to 10/24/24. All other terms and conditions remain unchanged. FS 00 H312 00 1016 FailSafe © 2016, The Hartford q)0'fj' t- Douglas Elliot, President Page 1 of 1 ENDORSEMENT NO:20 This endorsement, effective 12:01 am, 10/24/24 forms part of policy number 46 TE 0281457-24 issued to: NMK CORPORATION by: HARTFORD FIRE INSURANCE CO. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIOR ACTS LIMIT RESTRICTION ENDORSEMENT (ONE LIMIT CHANGE) You and we agree that: Solely with regards to the Limits of Liability stated in item 4 of the Declarations that are: A. _1 QQQ,, 0..0..in excess of the first ! ! ,,,Q00 under the Each Wrongful Act Limit B. i ., 6 C in excess of the first 1 C C O i O under the Aggregate Limit Section III — Exclusions, is changed to add the following sub -section: We will not pay damages, first party expenses, or claim expenses or defend any of you for any actual or alleged wrongful act that occurred prior to: 10/24/24 Nothing in this endorsement is intended, nor shall it be construed, to: • increase the Limits of Liability under this Policy stated in item 4 of the Declarations, or 0 obligate or require us to pay damages, first party expenses, or claims expenses under this Policy in any amount exceeding the Limits of Liability under this Policy stated in item 4 of the Declarations. All other terms and conditions remain unchanged. qa'�&' t Douglas Elliot, President FS 00 H328 00 1016 FailSafe Page 1 of 1 © 2016, The Hartford ENDORSEMENT NO:21 This endorsement, effective 12:01 am, 10/24/24 forms part of policy number 46 TE 0281457-24 issued to: NMK CORPORATION by: HARTFORD FIRE INSURANCE CO. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. RETENTION CHANGE - INCREASE You and We agree that: Item 5. Retention Each Wrongful Act of the Declarations is deleted and replaced with the following: 3. Retention Each Wrongful Act $5,QLO All other terms and conditions remain unchanged. (;�Ok�ao Douglas Elliot, President FS 00 H338 00 1016 FailSafe Page 1 of 1 © 2016, The Hartford 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 Name of Agent Policy Number Expiration Date Phone # (?t) I certify that, in the performance of the work set forth in the agreement with the City of E'i 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 ,1/4 Z-1 Dateox�o� o a Print Name Nabeel Khatri Agreement for: Dated: Reviewed by: