PROOF OF INSURANCE (2016) CLOSEDe " DATEIMfaMD1YYVVI
AC<DIIRV CERTIFICATE OF LIABILITY INSURANCE
08125,12016
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT- If the certificate holder Is an ADDITIONAL INSURED, the policy(les) must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION 13 WAIVED, subject to the Isms and conditions of 11ho policy, certain policies may require an endorsement. A statement on
this certificate does not confor riahts; to the corliftate holder In lieu of such andarsemani(s).
PRODUCER
State Fann CRISTIAN AMAYA STATE FARM
682 W 9TH ST
orb
SAN PEDRO CA 90731
InSURED
GERMAN DELGADO
D13A D.0 ELITE AUTO DETAILING
1111 VVFST
NLMINGTON CA 90744
COVERAGES CERTIFICATE NUMBER:
F-o""A" VERONICAFLORES
4244775887 FAX NIP1 l 424217490B
— f&q , -
DRES�< VEROhICA,FI,ORF-�5,FfAZ4@STATCFARM.CChi
NAIC 0
State Form Fire and Casualty Company 25143
INSURER 0,
INSURER C:
IN
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INSURERS,
F ; 7
REVISION NUMBER:
THIS IS To CERTIFY IJIAI 1f II; POLICIES OF INSIJRANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSORFO NAMED ABOVE FOR THE POLICY P111410D
INDICATED. NOTOATHSTANDING ANY REOUIREMENT TERM OR CONDITION
OF ANY CONTRACT OR OTHER DOCUMENT VATH RESPECT TO VMICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN THE INSURANCE AFFORDED BY TILE POLICIES DESCRIBED HEREIN 15 SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND CONDITIONS OF StIrK POLICIES, LIMITS SH(YtVN MAY
HAVE BEEN REDUCED BY PAID CLAIMS.
IYPfi OF INSURANCE iqgn V
Policy(, xP
11PAr1a
X; COMMERCIAL GENERAL UAOILITY
5 1 11-00000
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DANIAGE TOREN'TtO 300,000
CLARAWAADE VCUq
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VIED kXP lArq -n Pn-I S (DG0
92-F-F•K461-6
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riopuyul$ -CWAP0AO5 S 2.000.0010.—.--
500'
AUTOMOBILE LIAMI-Ity
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ANY AIJTG
BODILY INJURY kPar rwrtw I S
ff., F n C"HEDULED
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UODILY INJURY (Pw rer'w"�
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D1!Sc1q1PTION OF OPERAT10115 I LOCATIONS I VEHICLES JACORG 101, AddiflaMAJ Rettla"M Schedule, may be altsch4a it men space Is r9quIred)
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
CITY OF EL SEGUNDO ACCORDANCE WITH THE POLICY PROVISIONS.
350 MAIN ST AUTHORIND 1111SPRESE11TATM
EL SEGUNDO, CA 90245
0 198,8.2016 ACORD CORPORATION. All rights reserved,
ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD !011164 13.14141.12 03.•2010
TL Policy No. 92 EFK461 6 0984 —FA34 CMP- 4766.1
Page 1 of 2
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
CMP- 4786.1 ADDITIONAL INSURED — OWNERS, LESSEES, OR CONTRACTORS
(Scheduled)
This endorsement modifies insurance provided under the following:
BUSINESSOWNERS COVERAGE FORM
SCHEDULE
Pollcy Number: 92 EFK4 61 6
Named Insured:
DELGADO, GERMAN
1111 W F ST
WILMINGTON CA 90744 5006
Name And Address Of Additional Insured Person Or Organization:
CITY OF EL SEGUNDO ITS OFFICER OFFICIALS EMPLOYEES AGENTS & VOLUNTEERS
350 MAIN ST
EL SEGUNDO CA 90245 3813
1. SECTION II — WHO IS AN INSURED of
b. If coverage provided to the additional In-
SECTION II — LIABILITY is amended to In-
sured is required by a contract or agree -
clude, as an additional insured, am person or
ment, the insurance provided to the
orgganization shown In the Schedu a, but only
additional insured will not be broader than
with respect to liability for '"bodily Injury",
" ", " "personal
that which you are required by the contract
property p "damage or and adverts-
ing Injury caused, In whole or In part, by:
or agreement to provide for such addition -
al insured; and
a. Ongoing Operations
(1) Your acts or omissions: or
c. If the contract or agreement between you
the insured is by
and additional governed
(2) The acts or omissions of those acting
California Civil Code Section 2782 or
on your behalf;
2782.05, the insurance provided to the
additional Insured is the lesser of that
In the performance of our ongDing opera-
which:
tions for that additional insuracl: or
b. Products – Completed Operations
b. P
(1) Is allowed for the satisfaction of a de-
fense or indemnity obligation by Cali-
"Your work "" performed for that additional
fornia Civil Code Section 27"82 or
Insured and Included In the "products-
2782.05 for your sole liability; or
completed operations hazard ".
(2) You are required by contract or
However, Paragraph 1. above is subject to the
agreement to provide for such addi-
following:
tional insured.
a. The Insurance afforded to the additional
We have no duty to defend or Indemnify the
Insured only applies to the extent permit-
additional insured under, this endorsement un-
ted by law;
til a claim or "suit" Is tendered to us.
O. Copyri�ghl, 'State Iran Mutusl Automoobile Insurance Company, 2018
Includes copyaig1 tot! materiel of ins 8URNN'r lcas Otltce, Inc., with Its permission.
2. Any insurance provided to the additional in-
sured shall only apply with respect to a claim
made or a " "suit" hwrought for damages for
which you are provided coverage,
3. With respect to the Insurance afforded to the
additional Insured, the followingg Is added to
SECTION II LIMITS OF INSURANCE:
If coverage provided to the additional Insured
is required, by contract or agreement, the most
we will ppay on behalf of the additional Insured)
will be t, as lesser of the amount of Insurance:
a. Required by the contract or agreement; or
b. Available under the applicable Limits Of
Insurance shown in the Declarations.
This endorsement shall not increase the ap-
plicable Limits Of Insurance shown in the
Declarations„
4. With respect to the Insurance afforded to the
additional insured, the following Is added to
Paragraph 3. Duties In The Event Of Occur-
rence, Offense, Claim Or Suit of SECTION
II — GENERAL CONDITIONS:
The additional insured must:
a. See to It that we are notified as soon as
P recticable of an " "occurrence "" or an of-
ense which may result In a claim. To the
extent possible, notice should Include:
(1) How, when and where the "occur-
rence" or offense took place;
(2) The names and addresses of any in-
jured persons and witnesses; and
CMP- 4788.1
CMP -4786.1
Page 2 of 2
(3) The nature and location of any injury
or damage arising out of the "occur-
rence" or offense;
b. Tender the defense and Indemnity of any
claim or "suit" to us and to all other insur-
ers who may have insurance potentially
available to the additional insured; and
c. Agree to make available any other Insur-
ance the additional Insured has for de-
fense or damages for which we would
E rovide coverage under SECTION II —
[ABILITY,
5. With res act to the Insurance afforded the ad-
ditional irnsured, the following replaces SEC-
TION II —LIABILITY of Paragra h 7. Other
Insurance of SECTION I AND S�TION II —
COMMON POLICY CONDITIONS:
a. This insurance Is primary to and will not
seek contribution from any other insurance
available to the additional, insured, provided
that the additional Insured) is a named In-
sured under such other insurance.
b. Regardless of any, agreement between
you and the additional insured, this Insur-
ance Is excess over any other insurance
whether primary, excess, contingent or on
any other basis for which the additional In-
sured has been added as an additional In-
sured on other policies.
There will be no refund of premium in the event
this endorsement is cancelled.
All other policy provisions apply.
1007033 148011 08.21 -2014
O, Copyr9 hi, state Farm Mutual Automobile Insurance Company, 2013
Includes oopyrig, led material of Insurance Sory1cas Ofte, Inc., with Its permission.
State Fenn°
Providing Insurance and Rnancial Services
900 OW River Road
BakarsRNd CA 93311-8501
Attached as requested are your replacement insurance identification cards. If the attached cards are not accepted
by a law enforcement agency or your Department of Motor Vehicle office, please contact your agent to receive
additional assistance.
Thank you for choosing State Farm for your insurance needs.
------------------------------------- - - - -�4
IMPORTANT - IDENTIFICATION CARDS
STATE FARM
t to a r m CALIFORNIA
INSURANCE CARD
aqfar Farm Mutual Autm4bflo Insurawo Co ry ry
B TI� CRA 11-85 VOA
"W" 2508 0984 -AS4
THE POLICY MEMO THE MINIMUM LIABILITY LIMITS
't fe&r
THIS CARD MUST BE KEPT IN THE INSURED MOTOR
VEHICLE FOR PRODUCTION UPON DEMAND.
m¢
KEEP A CARD IN YOUR CAR.
THIS CARD IS INVALID IF THE POLICY FOR WHICH IT WAS ISSUED LAPSES OR IS TERMINATED,
KEEP YOUR CURRENT CARD UNTIL THE EFFECTIVE DATE OF OF THIS CARD.
ONE COPY OF THIS FO BE PATH INEFM OGLE T ITIM M rNO TI RdS%N�Y DDOM,E OF INSURANCE IN COURT.
A I lroe a larlwlo 4 r�»rrr6la n+sl a a6 en yw Iira n evd
.---- ------------------ ------------- - - - -�-t
IMPORTANT - IDENTIFICATION CARDS
STATE FARM
StateFarm CALIFORNIA 'tT e wi
THIS CARD Muar eE KEPT IN THE INSURED MOTOR
INSURANCE CARD a VEHICLE FOR PRODUCTION UPON DEMAND
1434868 (oleoeele) 104*M4 A toil r onber lo a+rallaMs for MwWoy oo and Is Ioaalad on you► Ineuana and
MAY 4S 2016
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 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 become subject to the workers' compensation provisions of Labor Code § 3700 1 must
immediately comply with thos rovision r t e ament will, automatically become void.
Signature of Applicant Date 8/31/16
Agreement for 4 r 4Y)( *-
Dated: 'l
Reviewed by