PROOF OF INSURANCE (2004) CLOSED04/02/2003 02:45 3108233046
PAGE 01
A CERTIFICATE OF LIABILITY INSURANCE Q3/31/20/20 03
PRODUCER
TONY HQFFMAN
1117 11TH ST. SUITE 102
MANHATTAN BEACH, CA. 90266
310 821 -4321 FAX 310 823 -3046
Tm CaRWICATE IS WGUED At A NATTER OF MPORMATIOM
HOLDER. THUS CER14TMATE DOES MDT AMEND, EXTEMID 011
ALTER THE COVERAOE AFFORDED By THE POUCHES sam.
MU MSAFFOROMNOCOVERAOE
X UR01 MARK WILLIAMS (AM, J0>M ' PAIWTTING)
654 W. PALM AVE
EL SEGUNDO, CA. 90245
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TMB POLICIES OF INSmucE LISTED BELOW HAVE BEEN MM TO THE WOWED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDIM&I
ANY VJWk VMNT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MPkY iE IMUWD OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POL oWS DEBCROW HEREIN 18 SLIBJECT TO ALL THE TWRMB, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY NAVE BEEN REDUCED By PAID CLAMS.
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POLICYHOLDER COPY
STATE P.O. BOX 420807, SAN FRANCISCO, CA 94142 -0807
COMPENSATION
I N S U R A N C E
FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
APRIL 1, 2003 GROUP: 000229
POLICY NUMBER: 25035 -2002
CERTIFICATE ID: 4
CERTIFICATE EXPIRES: 07 -01 -2003
07 -01- 2002/07 -01 -2003
CITY OF EL SEGUNDO
ATTN: PATTY KIGHT
350 MAIN STREET CITY HALL LICENSE #512214
EL SEGUNDO CA 90245
This is to certify that we have issued a valid Worker's Compensation insurance policy in a form approved by the California
Insurance Commissioner to the employer named below for the policy period indicated.
This policy is not subject to cancellation by the Fund except upon 10 days advance written notice to the employer.
We will also give you 10 days advance notice should this policy be cancelled prior to its normal expiration.
This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the
policies listed herein. Notwithstanding any requirement, term or condition of any contract or other document with
respect to which this certificate of insurance 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.
774,11 GT/j Qw'
AUTHORIZED REPRESENTATIVE
k,. e. �
PRESIDENT
EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE
EMPLOYER
WILLIAMS, MARK THOMAS DBA: JON ROO PAINTING
654 PALM AVE
EL SEGUNDO CA 90245
31-�6
SCIF 10262E rEPF -UI: BO 1