PROOF OF INSURANCE (2026)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 ATTORNE-Y-S FEES -
with the City of El Segundo -
PolicyNo—...— ...... ..... -- . . . . . ........... .. ..........
L) I have and will maintain workers' compensation insurance as required by Labor Code § 3700 for the performance
kjA MAV� nee
carrier and policy nurriber are:
Carrier
Name of Agent
,z
certify that, in the pc4formance 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 bocorne %ject to the workers' compensation provisions of Labor Code 3700 1 must
immediately comply with than pII or the.-agIIeernant wilt aulornabcoHy become void. IV
I 7�5
Date
42, 111
Signature of App, ." 1,211]ft �---
Print Name
Agreement for:
Dated:
Reviewed by.
-
Policy Number Expiration Date
Phone #