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PROOF OF INSURANCE (2026)State Farm Insurance PO Box 2915 Bloomington, IL 61702-2915 WELL, CAROL i a4lk, State `crin State Farm General Insurance Company Your State Farm Agent Ed Barnhart 502 Main Street El Segundo CA 90245-3005 Bus: 310-322-8911 Email: ed.bamhart.b9aw@statefarm.com Policy number: 92-AO-NO40-0 Effective date: September 1, 2025 Policy period: 12 months Expiration date: September 1, 2026 The policy period begins and ends at 12:01 am standard time at the premises location. BUSIINIESSCWNERS POLICY Automatic renewal - If the State Farm® policy period is shown as 12 months, this policy will be renewed automatically subject to the premiums, rules and forms in effect for each succeeding policy period. If this policy is terminated, we will give you and the Mortgagee/Lienholder written notice in compliance with the policy provisions or as required by law. NAMED INSURED WELL, CAROL ENTITY Sole Proprietorship -Individual F10I,,,ICY PKIIVII,A'M This is not a bill. If an amount is due, then a separate statement will be sent prior to the due date. The premium(s) shown below is the 12 months premium(s) for the characteristics of the policy as described in this Declarations. Premium: $325.00 Total Premium: $325.00 Minimum Premium Discounts applied: Business Experience Rating Years in Business Renewal Discount Business in Residence Premises INPOR'TAN"I' NIIIS,SSAGF,:(S) Notice - Information concerning changes in your policy language is included. Please call your agent if you have any questions. Policy number: 92-AO-NO40-0 © Copyright, State Farm Mutual Automobile Insurance Company, 2008 CMP Dec CA CMP-4000 Page 1 of 1009178 2019 152395 219 05-17-2025 �d t'i� �������r����������������t�����!(ll.`��1����V1'l!! r������lrll%✓V��J��>�Ii1J�PINYr��%�%l�Gr,/6/!„�f rr 1?�,l�,i! ��t. rJ!"/�/7^�lil,�.�..A!I�I�t9�1�/t�IY,F���7u'./J�"�!Y71,���w���IIY���;ir���11W!lll��Idk� SEur lay d . PROPERTY Cd' l:...DULE Location Location of described premises Limit of Insurance* Limit of Insurance* Seasonal Increase - number Coverage A - Coverage B - Business Business Personal Property Buildings Personal Property 001 No Coverage $2,600 25% EL SEGUNDO CA 90245-2205 ' As of the effective date of this policy, the Limit of Insurance as shown includes any increase in the limit due to Inflation Coverage. SEC.111014 d dNlFLATION COVE RAGId'NI)E (ES) Cov A - Inflation Coverage Index: NIA Cov B - Consumer Price Index: 319.8 SEC11101Y II -- DEDUC111H.tLES BASIC DEDUCTIBLE $1,000 SPECIAL DEDUCTIBLES: Equipment Breakdown: $1,000 Money and Securities: $250 Other deductibles may apply - refer to policy. SIEc rm d II.111'"ENS11ONS OF CO IEd'tA01f : ,, LdIMdT Or:, INSURANCE - Ir;;;ACH IDESCRIRII:JC) PRI..dVdSd. S The coverages and corresponding limits shown below apply separately to each described premises shown in these Declarations, unless indicated by "See schedule". If a coverage does not have a corresponding limit shown below, but has "Included" indicated, refer to that policy provision for an explanation of that coverage. Coverage Limit of Insurance Accounts Receivable On Premises $10,000 Off Premises $5,000 Arson Reward $5,000 Collapse Included Damage to Non -owned Buildings from Theft, Burglary or Robbery Coverage B Limit Debris Removal 25% of covered loss Equipment Breakdown Included Fire Department Service Charge $2,500 Fire Extinguisher Systems Recharge Expense $5,000 Forgery or Alteration $10,000 Glass Expenses Included Increased Cost of Construction and Demolition Costs (applies only when buildings are insured on a 10% replacement cost basis) Money Orders and Counterfeit Money $1,000 Policy number:92-AO-NO40-0 Page 2 of 5 © Copyright, State Farm Mutual Automobile Insurance Company, 2008 CMP4000 A State Farin Coverage Limit of Insurance Money and Securities On Premises $5,000 Off Premises $2,000 Newly Acquired Business Personal Property (applies only if this policy provides Coverage B - Business $100,000 Personal Property) Newly Acquired or Constructed Buildings (applies only if this policy provides Coverage A - Buildings) $250,000 Ordinance or Law - Equipment Coverage Included Outdoor Property $5,000 Personal Effects (applies only to those premises provided Coverage B - Business Personal Property) $2,500 Personal Property Off Premises $15,000 Pollutant Clean Up and Removal $10,000 Preservation of Property 30 days Property of Others (applies only to those premises provided Coverage B - Business Personal $2,500 Property) Signs $2,500 Valuable Papers and Records On Premises $10,000 Off Premises $5,000 SEC"II10II4 i .,,,, If; TIE';IN II' NR OF' CO"V"RAGE- II,,,IIP I'T OF INSURANCE - IRi.i.R U,a10l,,,.M The coverages and corresponding limits shown below are the most we will pay regardless of the number of described premises shown in these Declarations. Coverage Limit of Insurance Loss of Income and Extra Expense 12 Months Actual Loss Sustained SE°:C'1110N H - L CATnN SCil,,,EDULJ:::: Location Location of described premises number 001 EL SEGUNDO CA 90245-2205 Policy number: 92-AO-NO40-0 ©Copyright, State Farm Mutual Automobile Insurance Company, 2008 CMPa000 Page 3 of 5 w wiu is i... iry uw i m &mmw aaim m SECTION H, LJAIBIIG.IIry Coverage Limit of Insurance Coverage L - Business Liability Per Occurrence $1,000,000 Coverage M - Medical Expenses $5,000 Any One Person Damage to Premises Rented to You $300,000 Aggregate Limits Limit of Insurance General Aggregate $2,000,000 Products/Completed Operations Aggregate $2,000,000 Each paid claim for Liability Coverage reduces the amount of insurance we provide during the applicable annual period. Please refer to Section II — Liability in the Coverage Form and any attached endorsements. Your policy consists of these Declarations, the BUSINESSOWNERS COVERAGE FORM shown below, and any other forms and endorsements that apply, including those shown below as well as those issued subsequent to the issuance of this policy. FORMS AND E;NftOI'tSQi:IIDIE'N"'I'S CMP-4101 Businessowners Coverage Form CMP-4260.2 Amendatory Endorsement (Califomia) CMP-4587 Exclusion - Silica or Silica -Related Dust CMP-4705.2 Loss of Income and Extra Expense CMP-4709 Money and Securities CMP-4860.2 Additional Insured - Designated Person or Organization FD-6007 Inland Marine Attaching Declarations FE-6999.3 Policyholder Disclosure Notice of Terrorism Insurance Coverage 'New Form Attached SCIHIEID!UII,,,,IE OF ADIDII'11101NA1,,, ul4-rElIEST(S) Interest type: Designated Person or Organization Interest type: Designated Person or Organization Endorsement number: CMP-4860.2 Endorsement number: CMP4660.2 Loan number: NIA Loan number: NIA THE CITY OF EL SEGUNDO, ITS ELECTED AND APPOINTED OFFICIALS, THE CITY OF EL SEGUNDO, ITS OFFICERS, OFFICIALS, EMPLOYEES, EMPLOYEES AND VOLUNTEERS AGENTS AND VOLUNTEERS 350 Main St 350 Main St SN El Segundo CA 90245-3813 El Segundo CA 90245-3813 r. This policy is issued by the State Farm General Insurance Company. ICAO°F"II"VI IIPA"1iNG F101-UCY You are entitled to participate in a distribution of the earnings of the company as determined by our Board of Directors in accordance with the Company's Articles of Incorporation, as amended. In Witness Whereof, the State Farm General Insurance Company has caused this policy to be signed by its President and Secretary at Bloomington, Illinois. c President Policy number:92-AO-NO40-0 CMP-4000 Secretary © Copyright, State Farm Mutual Automobile Insurance Company, 2008 Page 4 of 5 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. L) 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 # �) 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 becomes subject to the workers' compensation provisions of Labor Code § 3700 1 must immediately comply with those provisions or the a greement will auttornatically become void. Signature of App �� arl z Date � Print Name Agreement for: Dated: Reviewed by,