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PROOF OF INSURANCE (2017 - 2017) CLOSED A�? DATE(MMlDDlYYYY)
CERTIFICATE OF LIABILITY INSURANCE 1/4/2017
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.
1001 TANT: 'If the certificate holder Is an ADDITIONAL INSURED,the'pollcy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the pollcy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder In lieu of such ment(s . .
PRODUCER DANMTE c'r'Densse Bla
en cars .
nton
o.EaOl.m.. ., ._..__._._. (619)683-9999
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A406900,DeniseB@ehronfoldinsurance.com
_.. (619 1 663-999........._....V„
Michael Ehrenfeld Company (619)683-9990
2655 Camino Del Rio North DeniseB @ehrenfeldinsurance.com
4200 _ .. ..,_I ' ggKqJS)AFFOR'DINGCOVERAG ..._.- r..__._ )IAICo
San Diego CA 92108 INSURERA:Sentinel Insurance Co.. Limited 11.000
._..._..�.,-,.. . .. .,,, .... . .-., _ ...._SIR.........._..�_,.-...._._
INSURED IN ER e
Neal Alagia INSURER C
DBA Alagia Engineering INSURER D: _
17743 Del Paso Dr INSURER E:
Poway CA 92064 INSURE RF:
COVERAGE:$ CERTIFICATE NUMBER.2016 Master 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.
INSR 'AVb111WVI POLICY EFF POLICY EXP '
DR I TYPE OF INSURANCE I t�I POLICY NUMBER IYYYYI 1 UMIrS
I X y COMMERCIAL GENERAL LIABILITY ' EACH OCCURRENCE
E 0m�0
A CLAIMS-MADE X�OCCUR 1,000,.O -
00
X 72SBMAP2639 11/11/2016 11/11/2017 MED EXP(Any one porwn) S 10,000
u (PERSONAL 8 ADV INJURY S
1,000,000
OEWL AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 2,000,000
POLICY I u PRO• n
JECT LOC PRODUCTS-COMPaOP AGG S 2,000,000
OTHER Non-ox Is 11000,000
AUTOMOBILE
AUTO LIABILITY
� COh1101NE0 SINGLE Lu'fn°IiT S 1,000,000
A BODILY INJURY(Per Person) S
ALL OVMIED SCHEDULED 72SBM112639 11/11/2016 11/11/2017 BODILYINJURY(Peraccident), $
AUTOS AUTOS PROPERTY DAMAGE
X HIREDAUTS X AUTOS 1pot derdl $
S
UMBRELLA LIAB HCLAIMS-MADE EACH OCCURRENCE S
I OCCUR
EXCEISS UA AGGREGATE S
AND DED I I RETENTIONS I I S
WORKERS COMPENSATION PER OTH-
EMPLOYERS'LIABILITY YIN uIaA�I� E_ ER
ANY PROPRIET'ORdPAR'TNER EXECLkTiVE N r A E L EACH ACCIDENT S
OFFICE110MENBER EXCLUDEOm'
1('Wadatory In NH) E L DISEASE-EA EMPLOYE S
"M dosrrwhsl under
D RIPTION OF OPERATIONS Aeloµw E DISEASE-POLICY LIMIT S
I
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Romorks Schedule,may no attached It more space Is required)
City of El Segundo is included as Additional Insured as required by written contract, as respects to
Commll General Liability, but limited to the operations of the Insured under said contract, and always
subject to the policy terms, conditions and exclusions per attached policy form IH12001185 on the primary
6 non-contributory basis per attached policy form SS00080405
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of El Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELMERED IN
350 Main Street ACCORDANCE WITH THE POLICY PROVISIONS.
E1 Segundo, CA 90245
AUTHORIZED REPRESENTATIVE
Joseph Erie/DS �
©1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
INS025 po1ao1)
POLICY NUMBER: 72 SBM AP2639 14
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - PERSON-ORGANIZATION
CITY OF EL SEGUNDO
350 MAIN STREET
EL SEGUNDO, CA 90245
Form IH 12 0011 85 T SEQ. NO. 001 Printed in U.S.A. Page 001
Process Date: 09/19/16 Expiration Date: 11/11/17
BUSINESS LIABILITY COVERAGE FORM
(6) When You Are Added As An When this insurance is excess over other
Additional Insured To Other insurance, we will pay only our share of
Insurance the amount of the loss, if any, that
That is other insurance available to exceeds the sum of:
you covering liability for damages (1) The total amount that all such other
arising out of the premises or insurance would pay for the loss in the
operations,or products and completed absence of this insurance;and
operations, for which you have been (2) The total of all deductible and self-
added as an additional insured by that insured amounts under all that other
insurance; or insurance.
(7) When You Add Others As An We will share the remaining loss,if any,with
Additional Insured To This any other insurance that is not described in
Insurance this Excess Insurance provision and was not
That is other insurance available to an bought specifically to apply in excess of the
additional insured. limits of Insurance shown in the
However, the following provisions Declarations of this Coverage Part.
apply to other insurance available to c. Method Of Sharing
any person or organization who is an If all the other insurance permits
additional insured under this Coverage contribution by equal shares,we will follow
Part: this method also. Under this approach,
(a) Primary Insurance When each insurer contributes equal amounts
Required By Contract until it has paid its applicable limit of
This insurance is primary if you insurance or none of the loss remains,
have agreed in a written contract, whichever comes first.
written agreement or permit that If any of the other insurance does not permit
this insurance be primary. If other contribution by equal shares, we will
insurance is also primary, we will contribute by limits. Under this method, each
share with all that other insurance insurer's share is based on the ratio of its
by the method described in c. applicable limit of insurance to the total
below. applicable limits of insurance of all insurers.
(b) Primary And Non-Contributory 8. Transfer Of Rights Of Recovery Against
To Other Insurance When Others To Us
Required By Contract a. Transfer Of Rights Of Recovery
If you have agreed in a written If the insured has rights to recover all or
contract, written agreement or part of any payment, including
permit that this insurance is Supplementary Payments, we have made
primary and non-contributory with under this Coverage Part, those rights are
the additional insured's own transferred to us. The insured must do
insurance, this insurance is nothing after loss to impair them. At our
primary and we will not seek request, the insured will bring "suit" or
contribution from that other transfer those rights to us and help us
insurance. enforce them. This condition does not
Paragraphs(a)and (b)do not apply to apply to Medical Expenses Coverage.
other insurance to which the additional b. Waiver Of Rights Of Recovery (Waiver
insured has been added as an Of Subrogation)
additional insured.
If the insured has waived any rights of
When this insurance is excess, we will recovery against any person or
have no duty under this Coverage Part to organization for all or art of an payment,
defend the insured against an suit if an g p y p y
g y"suit" y including Supplementary Payments, we
other insurer has a duty to defend the have made under this Coverage Part, we
insured against that "suit". If no other also waive that right, provided the insured
insurer defends, we will undertake to do waived their rights of recovery against
so, but we will be entitled to the insured's such person or organization in a contract,
rights against all those other insurers. agreement or permit that was executed
prior to the injury or damage.
Form SS 00 08 04 05 Page 17 of 24
BUSINESS LIABILITY COVERAGE FORMr� .,,.W .°
F. OPTIONAL ADDITIONAL INSURED 3. Additional Insured -Grantor Of Franchise
COVERAGES WHO IS AN INSURED under Section C. is
If listed or shown as applicable in the Declarations, amended to include as an additional insured
one or more of the following Optional Additional the person(s) or organization(s) shown in the
Insured Coverages also apply. When any of these Declarations as an Additional Insured -
Optional Additional Insured Coverages apply, Grantor Of Franchise, but only with respect to
Paragraph 6. (Additional Insureds When Required their liability as grantor of franchise to you.
by Written Contract, Written Agreement or Permit) 4. Additional Insured - Lessor Of Leased
of Section C., Who Is An Insured, does not apply Equipment
to the person or organization shown in the a. WHO IS AN INSURED under Section C.is
Declarations. These coverages are subject to the amended to include as an additional
terms and conditions applicable to Business insured the person(s) or organization(s)
Liability Coverage in this policy, except as shown in the Declarations as an Additional
provided below: Insured — Lessor of Leased Equipment,
1. Additional Insured - Designated Person Or but only with respect to liability for "bodily
Organization injury", "property damage" or "personal
WHO IS AN INSURED under Section C. is and advertising injury" caused, in whole or
amended to include as an additional insured in part, by your maintenance, operation or
the person(s) or organization(s) shown in the use of equipment leased to you by such
Declarations, but only with respect to liability person(s)or organization(s).
for "bodily injury", "property damage" or b. With respect to the insurance afforded to
"personal and advertising injury" caused, in these additional insureds, this insurance
whole or in part, by your acts or omissions or does not apply to any "occurrence" which
the acts or omissions of those acting on your takes place after you cease to lease that
behalf: equipment.
a. In the performance of your ongoing 5. Additional Insured - Owners Or Other
operations;or Interests From Whom Land Has Been
b. In connection with your premises owned Leased
by or rented to you. a. WHO IS AN INSURED under Section C.is
2. Additional Insured - Managers Or Lessors amended to include as an additional
Of Premises insured the person(s) or organization(s)
shown in the Declarations as an Additional
a. WHO IS AN INSURED under Section C. is Insured—Owners Or Other Interests From
amended to include as an additional insured Whom Land Has Been Leased, but only
the person(s)or organization(s)shown in the with respect to liability arising out of the
Declarations as an Additional Insured - ownership, maintenance or use of that part
Designated Person Or Organization;but only of the land leased to you and shown in the
with respect to liability arising out of the Declarations.
ownership, maintenance or use of that part of
the premises leased to you and shown in the b. With respect to the insurance afforded to
Declarations. these additional insureds, the following
additional exclusions apply:
b. With respect to the insurance afforded to
these additional insureds, the following This insurance does not apply to:
additional exclusions apply: (1) Any "occurrence" that takes place
This insurance does not apply to: after you cease to lease that land;or
(1) Any "occurrence" which takes place (2) Structural alterations, new
after you cease to be a tenant in that construction or demolition operations
premises; or performed by or on behalf of such
(2) Structural alterations, new person or organization.
construction or demolition operations 6. Additional Insured - State Or Political
performed by or on behalf of such Subdivision—Permits
person or organization. a. WHO IS AN INSURED under Section C.is
amended to include as an additional
insured the state or political subdivision
shown in the Declarations as an Additional
Page 18 of 24 Form SS 00 08 04 05
BUSINESS LIABILITY COVERAGE FORM
Insured — State Or Political Subdivision - (e) Any failure to make such
Permits, but only with respect to inspections, adjustments, tests or
operations performed by you or on your servicing as the vendor has agreed
behalf for which the state or political to make or normally undertakes to
subdivision has issued a permit. make in the usual course of
b. With respect to the insurance afforded to business, in connection with the
these additional insureds, the following distribution or sale of the products;
additional exclusions apply: (f) Demonstration, installation,
This insurance does not apply to: servicing or repair operations,
(1) "Bodily injury", "property damage" or except such operations performed
at the vendor's premises in
"personal and advertising injury" connection with the sale of the
arising out of operations performed for
the state or municipality; or product;
( ) y injury"2 "Bodil u " "property " (9) Products which, after distribution
dama g e or sale by you, have been labeled
included in the "product-completed or relabeled or used as a
operations"hazard. container, part or ingredient of any
7. Additional Insured—Vendors other thing or subtance by or for
a. WHO IS AN INSURED under Section C.is the vendor;or � /`
amended to include as an additional (h) "Bodily injury" or "property
insured the person(s) or organization(s) damage" arising out of the sole
(referred to below as vendor)shown in the negligence of the vendor for its
Declarations as an Additional Insured - own acts or omissions or those of
Vendor, but only with respect to "bodily its employees or anyone else
injury" or 'property damage" arising out of acting on its behalf. However,this
"your products" which are distributed or exclusion does not apply to:
sold in the regular course of the vendor's (i) The exceptions contained in
business and only if this Coverage Part Subparagraphs(d)or(f);or
provides coverage for "bodily injury" or (ii) Such inspections,
property damage, included within the
"products-completed operations hazard". adjustments, tests or servicing
b. The insurance afforded to the vendor is as the vendor has agreed to
make or normally undertakes
subject to the following additional exclusions: to make in the usual course of
(1) This insurance does not apply to: business, in connection with
(a) "Bodily injury" or "property the distribution or sale of the
damage" for which the vendor is products.
obligated to pay damages by (2) This insurance does not apply to any
reason of the assumption of insured person or organization from
liability in a contract or agreement. whom you have acquired such
This exclusion does not apply to products, or any ingredient, part or
liability for damages that the container, entering into,
vendor would have in the absence accompanying or containing such
of the contract or agreement; products.
(b) Any express warranty 8. Additional Insured—Controlling Interest
unauthorized by you; WHO IS AN INSURED under Section C. is
(c) Any physical or chemical change amended to include as an additional insured
in the product made intentionally the person(s) or organization(s) shown in the
by the vendor: Declarations as an Additional Insured —
(d) Repackaging, unless unpacked Controlling Interest, but only with respect to
solely for the purpose of inspection, their liability arising out of:
demonstration, testing, or the a. Their financial control of you:or
substitution of parts under b. Premises they own, maintain or control
instructions from the manufacturer, while you lease or occupy these premises.
and then repackaged in the original
container;
Form SS 00 08 04 05 Page 19 of 24
BUSINESS LIABILITY COVERAGE FORM
This insurance does not apply to structural The limits of insurance that apply to additional
alterations, new construction and demolition insureds are described in Section D. — Limits Of
operations performed by or for that person or Insurance.
organization. How this insurance applies when other insurance
9. Additional Insured — Owners, Lessees Or is available to an additional insured is described in
Contractors — Scheduled Person Or the Other Insurance Condition in Section E. —
Organization Liability And Medical Expenses General
a. WHO IS AN INSURED under Section C. is Conditions.
amended to include as an additional G. LIABILITY AND MEDICAL EXPENSES
insured the person(s) or organization(s) DEFINITIONS
shown in the Declarations as an Additional
Insured—Owner, Lessees Or Contractors, 1. "Advertisement" means the widespread public
but only with respect to liability for"bodily dissemination of information or images that
injury", "property damage" or "personal has the purpose of inducing the sale of goods,
and advertising injury" caused, in whole or products or services through:
in part, by your acts or omissions or the a. (1) Radio;
acts or omissions of those acting on your (2) Television;
behalf: (3) Billboard;
(1) In the performance of your ongoing (4) Magazine;
operations for the additional (
insured(s); or 5) Newspaper;
(2) In connection with "your work" b. The Internet, but only that part of a web
performed for that additional insured site that is about goods, products or
and included within the "products- services for the purposes of inducing the
completed operations hazard", but sale of goods, products or services;or
only If this Coverage Part provides c. Any other publication that is given
coverage for "bodily injury" or widespread public distribution.
"property damage" included within the However, "advertisement"does not include:
products-completed operations
hazard" a. The design, printed material, information
or images contained in, on or upon the
b. With respect to the insurance afforded to packaging or labeling of any goods or
these additional insureds, this insurance products; or
does not apply to "bodily injury", "property b. An interactive conversation between or
damage" or "personal an advertising
injury" arising out of the rendering of, or among persons through a computer network.
the failure to render, any professional 2• "Advertising idea" means any idea for an
architectural, engineering or surveying "advertisement".
services,including: 3. "Asbestos hazard" means an exposure or
(1) The preparing, approving, or failure to threat of exposure to the actual or alleged
prepare or approve, maps, shop properties of asbestos and includes the mere
drawings, opinions, reports, surveys, presence of asbestos in any form.
field orders, change orders,designs or 4. "Auto" means a land motor vehicle, trailer or
drawings and specifications;or semi-trailer designed for travel on public
(2) Supervisory, inspection, architectural roads, including any attached machinery or
or engineering activities. equipment. But "auto" does not include
10. Additional Insured — Co-Owner Of Insured "mobile equipment".
Premises 5. "Bodily injury"means physical:
WHO IS AN INSURED under Section C. is a. Injury;
amended to include as an additional insured b. Sickness;or
the person(s) or Organization(s) shown in the c. Disease
Declarations as an Additional Insured — Co-
Owner Of Insured Premises, but only with sustained by a person and, if arising out of the
respect to their liability as co-owner of the above, mental anguish or death at any time.
premises shown in the Declarations. 6. "Coverage territory"means:
Page 20 of 24 Form SS 00 08 04 05
AC"° 'a CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY)
10/06/2016
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(ies) must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT JOHN A TRAN
Slatf.,Farm JOHN A TRAN PHONE.ga (619)291-1787 LAIC N' (619)291-6138
ADDRESS, 6• FAX
2820 CAMINO DEL RIO S STE 310 JOHN TRAN L8V Y�S d1
STATE COM
INSURER(S)AFFORDING COVERAGE NAIC N
SAN DIEGO,CA 92108-3821 INSURER A: State Farm General Insurance Company 25151
....
INSURED INSURER B..,,,.,
ALAGIA ENGINEERING INSURER
17743 DEL PASO DRIVE INSURER D:
POWAY,CA 92064 INSURER E 7
INSURER F:
COVERAGES 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,
dNTR TYPE OF INSURANCE l INID WVD POLICY NUMBER (MMIDDIVY POLICY 90 VXL 0I.ICY iw .. „......
„ _ ,,,,,,, fODIYYYN LIMITS
LIABILITY TO $ J
DAMAGE COMMERCIAL GENE EACH OCCURRENCE RENTED
CLAIMS-MADE I I OCCUR PREMISES(Fa o%yrrence) $
(Any one person)
PERSONAL&ADV INJURY $
GEN'L AGGREGATEE LIMIT APPLIES PER GENERAL AGGREGATE $
Po',I Y 1EC7 d.00
UCTS-COMP/OPAGG $
BUS
OTHER $
...............�.......................
AUTOMOBILE LIABILITY
Eaacud DCp If�YR�LE0 LIMIT
,,, $
ANY AUTO BODILY INJURY(Per person) $
OWNED SCHEDULED BODILY INJURY Per accident $
AUTOS ONLY AUTOS (Per
HIRED NON-OWNED pK;t,nP,.R�,T'y IUAk11,A'Gr.
AUTOS ONLY AUTOS ONLY (Por ocodoggp
..... ............................................................. .......... ..............__ $
UMBRELLA LIAR
OCCUR EACH O U,.RRENCE,,,,,,,,,,,,,,
EXCESS LIAB
Fr1 RETENTION$ CLAIMSMADE AGGREGATE �
n..
WORKERS COMPENSATION PER OTH- ..
AND EMPLOYERS'LIABILITY YIN STATUTE ER
ANY
MandaR/ME NH) E L DISEASE $
OFFICER/MEMBER EXCLUDED NIA E L EACH
(Mandatory ) ..,I YY SE-EA EMPLOYEE! $
If yes,describe under
DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $
..... .......................... ..._......�........
LIMIT OF LIAB $
ARCHITECTS AND ENGINEERS 2000000
PROF LIAB INSURANCE POLICY PS0000004710202 09/17/2016 09/17/2017 LMT LIAB EA CLAIM $2000000
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) _
PREMIUM-$2648
DEDUCTIBLES-$1000
CLIENT#-248279
..............................
__., w
!CERTIFICATE HOLDER CANCELLATION _
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
CITY OF EL SEGUNDO-PUBLIC WORKS ACCORDANCE WITH THE POLICY PROVISIONS.
350 MAIN STREET
EL SEGUNDO,CA 90245 AUTHORIZED REPRESENTATIVE
ATTENTION-JOHN GILMOUR
-------- -------- -----
©1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
1001486 13284912 03-16-2016
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.
(_)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 those prova' ns or a ,e lent will automatically become void.
Signature of Applicant a Date 9-13-16
Agreement for:
Dated: �, , .,.F°, ,�" A(.,;5
Reviewed by-,
1