PROOF OF INSURANCE (2017) CLOSEDAUTNORU:EO REPRUENTATNE
Amusement & Event Planners Insurance Specialists
ACORD 25 (2010/05) x141120.001 m 1888.2010 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD '
COMMERCIAL GENERAL LIABILITY
CG 20 26 07 04
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - DESIGNATED PERSON OR
ORGANIZATION
Policy Number. SRPGP- 101- 0716/USP222652
Insured: Ron lacopuccl dba Jump For Joy
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
Or
City of El Segundo
350 Main Street
El Segundo, CA 80245
to
SCHEDULE
Section II - WHO IS AN INSURED Is amended to
include as an Insured the person(s) or organization(s)
shown In the Schedule, but only with respect to liability
for 'bodily injury ", "property damage " or " personal and
advertising Injury "" caused, In whole or in part, by your
acts or omissions of the acts or omissions of those
acting on your behalf:
A. In the performance of your ongoing operations; or
B. In connection with your premises owned by or
rented to you,
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CG 20 26 07 04 0 180 Properties, Inc„ 2004 Page 1 of 1 C
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Automobile Policy Declarations
1. Named Insured
RON &VALERIE IACOPUCCI
530 S FRANCISCA AVE APT #B
REDONDO BEACH, CA 90277 -4241
Your Insurer
TRAVELERS COMMERCIAL INSURANCE COMPANY
ONE TOWER SQUARE, HARTFORD, CT 06183
Your Auto Policy Number 996024601 203 1
Your Account Number 941113867
ar ,+li a
Your Service Center Address
KNOXVILLE BUSINESS CENTER
P O BOX 59059
KNOXVILLE, TN 37950 -9059
For Policy Service 1- 800 - 842 -5075
For Claim Service 1- 800 -252 -4633
2. Premium
Your Total Premium for the Policy Period Is $1,341.
The policy period is from August 1, 2016 to February 1, 2017 12:01 A.M. STANDARD TIME at your address
shown in Item 1.
3. Your Vehicles Identification Numbers
1. 2006 TOYOT TUNDRA LIM 5TBDT48126S519837
2. 1990 FORD F350 2FDKF37M1 LCA88678
3. 2001 TOYOT AVALON XL/ 4T1 BF28B11 U131498
4. 2010 TOYOT PRIUS JTDKN3DUXA0148831
4. Coverages, Limits of Liability and Premiums
Insurance is provided only where a premium entry is shown for the coverage. The premium entry "Ind" or "Pkg"
means the premium charge is included in the premium for another coverage or a package.
VEHICLE 1 VEHICLE 2 VEHICLE 3 VEHICLE 4
A. Bodily Injury
$100,000 each person
$300,000 each accident
B. Property Damage
$50,000 each accident
D1. Uninsured Motorists Bodily Injury
$100,000 each person
$300,000 each accident
E. Collision
Actual Cash Value less
$2,500 deductible
T. Waiver of Collision Deductible
PL -50014 (03.12)
670 /OM 1605
06 TOYOT
90 FORD
01 TOYOT
10 TOYOT
TUNDRA LIM
F350
AVALON XU
PRIUS
$179
$210
$129
$151
$85
$75
$49
$60
$48
$63
$48
$50
$54
$26
$64
$2
$2
Page 1 of 4
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.
(--) 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#
(.X) 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 t provisi mss or t -agreement will automatically become void.
Signature of Applicant Date
Agreement for:
Dated: -LP-L C1, —10
Reviewed by: