PROOF OF INSURANCE (2027)Imm rblc OVINA12rd
IT IS AGREED, THAT THIS CERTIFICATE IS ISSUED TO, THE CER'HI HOLDER LISTED BELI TO CERTIFY
COVERAGE UNDER THE COMMERCIAL GENERAL LIABILITY INSURANCE KIIUCY ILMSTIED BELOW,
......................................................................... . . ....... . . . ..................................................... ...... . . . . . ........
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CERTIFICATE HOLDER., Heather Rosari* POLICY NUMBER:
N0221 GL010000 100
CERTIFICATE NUMBER -
ADORES&
............ . . . ....... . ................... CPTNIT239053
CERTIFICATE POILICY PERIOD. 011141 TO 011114/2027
5-49 il I AT Yl ADDRFSS SHOWN ASOVE,
..............................
UMITS OF INSURANCE
FORMS AND ENDORSEMENTS
THESE DF(CLARATONS, TOGETHER WITH THE COMMON POI CONDITIONS AND COVERAGE FORM(S) AND ANY
END ORSEMEN7(S�, COMPLETE THE ABOVE NUMBERED POIJCY, THESE DECLARATIONS, TOGETHER WfrH THE
C,OIMMON POLICY OONIXT$ONSAND, COVERAGE FORM(S) AND, ANY ENDORSEMENT�SJ,COMPLETE THE ABOVE
NUMBEREOPOLICY
Eml AIIWWPWJ W Oft 006qTIRLA10 IN 01I 2NM % a 14
B8 100,02 Pagie 1 cf 2!
ADDITIONAL COVERAGE OPTIONS - Coverago Applies When Checked
0 Cioppmg Endiairsemenil
[] Micro-Cuierent Endorsement
('.J DwWry and NutdilanIM EfOursement
I I Ad -hoc F ndoir%,- meat
* Fitness Endorsement
* Primary, Nwiamt6thitory
.".) Specific, Waiver 0 Subrogaflori
* Loss P'ayee
* PhrraryNoricarittibotary & Waivor of Siubtogation
I"-] C0 20 111 Addftnall Insuroid -- Maragers or Lessor's of Promh8as
IE� Eadior Notice of Canceflalion Providiod' dry B Is
U 1 Year - Extendied Repairing Period
fJ 2 yoar - Extended Reporting Penod
Cl 3, to au - Extended Reporting Pedod
Kireld aindl Noti-Owned Auto
E) Agent chainged
0 Account rnanarger clhalnqf,sd
.11Year ExtondodkopcdinjgFI06od(SL ILaxed)
U 2 year - E,Aended IReporlirtug Ptdodl (SL myxd)
Cl 3 Year - EAptidod Rvpodtng Parod (SL taxed),
0 WaNer of Subimgaborrij
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TWOS WSURANCE Ill.; SUBJECT TO ALL THE TERMS AND CONnITIONS, INGLUDIING APPUCABLE ENDORSEMENTS, OF THE
COMMERCIAL GIENERAL LIASUITY INSORANCE MASTER POLICY, A COPY OF I HE COMMERCIAL 0rJqLFtAL UAWLITY INSURMC IL
MASTr,,",RPOI,.11("YA(,COMPANIES]IH111"oCERTtBd,CA'IIE ADDITIONALCOpmsmu, acpRoviom"m THE CEFurlHCATE HOLDER
UPON PCOUEST. PLEASE READ T6 IE POLCY AND ALL Er DONSFMEN17S
CLAIM FMINCIDENTS REPORTING
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Full detall ofany irlidderd SWUM oeTien' , immediatefy by eMail W CWxns@(deal3.pom, Phow (Ed al) 443-3253, Fac (612i 230-9875o
or submit vla youir customer dashboard,
..... ........
NO ADO)SPOIN OF LIABlUrYMAY BE MADE EITHER VERBALLY OR IN WRIrTING
IN RETURN FOR P'AYM EN T OF THE PREWU M, AND su sj,Ec,r TO ALL OF THE PREMIUM $5700
TERMIS OF THE POLICY, WE A G NEE W'T Hi YOU TO, PROVIDE THIE INSURANCE SURPLUS LINES TAX $0 00
AS STATED IN TINS POUCY. STAMPM FEE $0 oo
TOTAL COST $57kif)
. . . . . .. .......................
Adm[pWratsd By;
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RepwN Grmyo alar,
AdmiA%tratof's Sjginature�
RACE', NATIONAL ORIGIN AND GENDER NOTICE - CALIFORNIA
co4d AA
. . .........
ggMeM Name: policy Number JF,or New Susiness Only) -
Accelerant National Insurance Company
400 Northridge Road,, Sulte 8100
Sandy Springs, GA 30O This information is requested by the State oonitor the insurer's compliance with the law.
AH new policyholders are requested to voluntarily provide the fol�lowing information. No such information shall
be used for the purposes of underwriting or rating any policyholder.
Policyholdler's Name and Address (to be provided in ordeir to refer back to the policy) Note: Use aiddi-
tionall forms If needed. ............. . .
NAMED INSURED:
MAILING ADDRIESS:
POLICY PER0D: FROM TO AT 12V A.M. STANDARD
TIME AT YOUR MAILllNG ADDRESS SHOWN ABOVE
7M.
Fire — Personal
ED
Homeowners
El
Private Ipassengier Auto Liability El
Fire — Cornmercial
Commercial Mufti-Pedl
E]
If the policyholder does
not wish to provide, the Department of Insurance with this information, please check
here: F-1
ANIC IL NI 00110 07 25 Page 1 of 2 13
Check the Rare or National Origin as it applies to the policyholder(s). For the purpose of completing this form,
the policyholder is defined ais: an individual, spouse, domestic partner, or business partner(s) named on the poll -
icy.
Race/Nafl2ral Origin
Policyhm lcNsrI
Male
Female
Non-Bina,
l us-nes,s
African American
American Indian or Allsakan Native
L--j
Asia n/Pacffic Islander
El
Latino
White
Other
Check the Race or National Origin as it applies to the Co-poilicyholder(s). For the purpose of completing this
i form, the Co -policyholder is defined as: an individual, spouse, domestic partner, or business partner(s) named
on the policy,
Race/Nationa:l Origin
F
Co-Policyhold
Male
Female
Non -I inary
Buisiness
African American
American Indian or Alsakan Native
AsianJlPacific Islander
Latino
White
0 t tie r
ANIC IL N 01010 07 25 Paige 2 of 2 13
CITY OF EL SEGUNDO
I affirm under penalty of pequiry under the laws of Caftfoirnia one of the following decranations:
U I have and wMI maintain a certificate,of consent of sel,Nnsure (brworkers'oompensafion, issued Iby the Dkeetor
of industrial Relations as pruivided for by Labor Code § 3,700 for the performance of Ifie wark set forth the agreement
with Me City of El Segundo.
Poiicy No.
C_) I ihave and will maintain workers' compensation Insurance as required by Labor Cade § 3700 for the performance
of the work for which, the agreament with ft City of El Segundo, is executed, My workers' compensaEon insurance
carrier and policy number are:
Canier Policy Number Expiration Date
Name of Agent Phone #
/s�awrffy that in the performance of the work set fodh In the agreement with the City of El Segundo, I will not
ernploy any person in, any manner so as to become subject to Vie workers' compansatitm laws of Califfornia, and
aeo that. if I should be ubject to the wo 00171pensation, provisions of Labor Code 3700, 1 must
immediately comply wftbh th Islon's or& agm n will aalofptcally bedorrje'vdd�l
1 4%141 pr
Signature of Applicant =?A�. 4 "� :A.
Print Name
Agreement f6rfug
Dated., 0
Reviewed b)r