PROOF OF INSURANCE (2026)^n"CoAnce CERTIFICATE NUMBER: A-SP.31J-25.01-06-327552 REVISION NUMUI=K'
.............. ..... . . .
THIS IS TO CERTIFY THAT THE POLICIES OFINSURANCEL IS FED BELOW BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THEPOLICY PERIOD INDICATED NO PNITHSTANDING A14Y REQUIREMENf, HERMORCONDI I ION
OF ANY CON IRACr OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERFIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS &JBJECr TO ALL FFIE TERMS
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
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POLICY EFF
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LIMITS
TYPE OF INSURANCE
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GENERAL LIABILITY
EACH OCCURRENCE
$ _1009—M-29--
A
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N
S0019GL000001-04
01106/2025
01106/2026
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X COMMERCIAL GENERAL LIABILITY
FIRE DAMAGE TO PREMISES
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CLAIMS -MADE r-7-1 OCCUR
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INCLUDES ATHLETIC PARTICIPANTS
PERSONAL& ADV INJURY
5 1 M0,000,00
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jjl�NERAJ_,� 2REGATE
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PRODUCTS- COMP/OP AG
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GENERAL AGGREGATE LIMIT APPLIES PER:
X POLICY PROJECT '4..00
S
AUTOMOBILE LIABLITY
COMBINED SINGLE LIMIT
(Ea accident)
ANY AUTO [_J� HIRED AUTOS
. . . . .........
BODILY INJURY Per person)
ALL OWNED NON -OWNED
AUTOS AUTOS
F1
BODILY INJURY (Per accident)
S
PROPERTY DANIAGE
SCHEDULED AUTOS
_IEREAc
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UMBRELLA LIAB OCCUR
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.
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EACH OCCURRENCE
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AGGREGATE.. .
$ . ....
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EXCESS LIAB
CLAIMS -MADE
DEDUCTIBLE
RETENTION S
VOCIFiCEPSCObVENSATION
7u "B
ANDEMPLOYEFISLABLITY
ANY PrOX44-t7CAPAR TNERvEXECUM
OFFICERMEIVIBEIR EXCLUDED?
E.L. FA.H ACCIDENT
5
N/A
If yes, describe under
SPECIAL PROVISIONS below
F L. 01,5FASE, FA EMPLOYEE
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E.L.OISEASE ROU�YLIVJ'r
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OTHER
A
Abuse/Molestation
N
N
S0019GL000001-04
01/06/2025
0110612026
........................ . . . . . . . ......
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 S 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
I City of El Segundo
,ANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF. NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS,
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.
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.
C__) 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 hate
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 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.
04.11.24
Signature of Applicant Date
IE �"
Print Name
Agreement for. Krystyna,Rodriguez
Dated: 04.11.24
Reviewed by: ! }