PROOF OF INSURANCE (2016) CLOSEDCERTIFICATE OF LIABILITY I S C 06/02/2016
THIS CERTIFICATE 18 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 be endorsed. if SUBROGATION IS WAIVED, subject to
the terns and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate h'old'er In lieu of such endorsementlsl,.
PRODUCER
Stratum Insurance Agency LLC
PO Box 273
The Small Business Team
949 - 270 -0609
tears stratuminsurance.com
Corona del Mar CA 92625
INSURER A: Catlin SpaclaV Insurance Company
15989
INSURED
INSURER
Maddison Jade Halverson
INSURER C
DBA: Farm Frlendz
I Rau
27725 Winding Way
Malibu CA 90265
s nsn F'
I 11RER F,
COVERAGE$ CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
I TYPE OF INSURANCE N LIMITS
A GENERAL LIABErTY X 0400100746 09/101201509/10/2016 EACH OCCURRENCE
5 1,000,000
COd14MERCIIALGENERAL UABILITY
5� 100,000
CLAIMS -MADE X OCCUR MED EXP ors
.5,000..
$ -�. AA�
PERSONAL S ADV INJURY
5 1,000,000
GENERAL AGGREGATE
5 2,000,000
GEWL AGGREGATE LIMITAPPLIS PER: PRODUCTS - COMP/OPAGO
_$1,000,000
X POLICY PIO; LOC
5
AUTOMOBILE
LIABILITY
A MIT
f
ANY AUTO
BODILY INJURY (Per person)
5
AALL OWNED SCHEDULED
BODILY INJURY (Per waldeM)
5
E
S
NON -OWNED
HIRED AUTOS AUTOS
i
UMBRELLA LIAR OCCUR EACH OCCURRENCE
5
EXCESS LIAB CUUMS -MADE AGGREGATE
5
PER R N I
5
WORKERS COMPENSATION ATU
AND EMPLOYERS' LIABILITY YIN
ANY PROPRIETORIPARTNERIEXECUTIVE E.L. EACH ACCIDENT
5
OFFICERIMEMBER EXCLUDED? NIA
(Mandatory In NH) E.L. DISEASE - EA EMPLOYEE
w
5
U deudbe under
DEIgRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMB
5
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES WWh ACORD 101, AddlSond Remarks Sowule, If more opus Is mgrrked)
The certificate holder is added as additional insured per policy form CG2011 as required by written contract
or agreement.
CERTIFICATE HOLDER CANCELLATION
City of El Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Attn: City Clerk ACCORDAEXPIRATION IH DATE POLICY PROVISIONS WILL BE DELIVERED IN
350 Main Street
El Segundo, CA 90245 AUTHORIZEDREPRESENTATNE
�GiVlD( �Gtl�6�
®1988 -2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD
POLICY NUMBER: 0400100746
COMMERCIAL GENERAL LIABILITY
CG 20 1104 13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
LESSORS ADDITIONAL INSURED - MANAGERS OR
I
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Designation Of Premises (Part Leased To You):
All premises leased to the Named Insured by a
written contract or agreement
Name Of Person(s) Or Organization(s) (Additional Insured):
All persons or organizations as required by a
written contract or agreement with
the Named Insured
Additional Premium:
Intormation required to ramglela this Schgdule, if not sbma a
A. Section II — Who Is An Insured is amended to
ave. will be a a Declaratiorls.
2. If coverage provided to the additional insured
include as an additional insured the person(s) or
is required by a contract or agreement, the
organizations) shown in the Schedule, but only
insurance afforded to such additional insured
with respect to liability arising out of the
will not be broader than that which you are
ownership, maintenance or use of that part of the
required by the contract or agreement to
premises leased to you and shown in the
provide for such additional insured.
Schedule and subject to the following additional B.
With respect to the insurance afforded to these
exclusions:
additional insureds, the following is added to
This insurance does not apply to:
Section III — Limits Of Insurance:
1. Any "occurrence" which takes place after you
If coverage provided to the additional insured Is
cease to be a tenant in that premises.
required by a contract or agreement, the most we
2. Structural alterations, new construction or
will pay on behalf of the additional Insured is the
demolition operations performed by or on
amount of insurance:
behalf of the person(s) or organization (s)
1. Required by the contract or agreement; or
shown in the Schedule.
2. Available under the applicable Limits of
However:
Insurance shown in the Declarations;
1. The insurance afforded to such additional
whichever is less.
Insured only applies to the extent permitted
This endorsement shall not increase the
by law; and
applicable Limits of Insurance shown in the
Declarations.
CG 20 110413 0 Insurance Services Office, Inc., 2012 Page 1 of 1
h �/
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
Name of Agent
Policy Number Expiration Date
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 KcKe subAl. the workers' compensation provisions of Labor Code § 370 I st
immediately comply wit p the agreement will automatically become void. , I fir
Signature of Applicant
Agreement for:
Dated: "l
µ
Reviewed b �
Y.
Date