PROOF OF INSURANCE (2017 - 2018) CLOSED 11,1%�E 04W,113[11 VVY
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THIS CERTIFICATE115 ISSUED AS A III Of INFORMATION OM111,1f AII'4110 CONFERS N112i RIGHT. .....................
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POLICY NUMBER: 13687479
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This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
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RENEWAL AU1 POLICY DECLARA T IONS
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Pii-,ioc,(,"ssed Date
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hAoinmetJoin regaiii a 11!`�y i ii wrease in prenAum due to the invoWemeim in any chars. New accridents mir coinvivitiorm con,
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OFRIGH',.IAL... HNSUREH) COPY yo
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 ATTORNEYS FEES.
1 affirm under penalty of perjury under the laws of California one of the following declarations:
(_)I have anti 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
M loy any person in any manner so as to ni subject to the workers' compensation laws of California, and
agree that, if I should become subject to tJ)e ,,wq ers' compensation provisions of Labor Code § 3700 1 must
immediately comply with those provisdr 11
f .greenient will automatically become void.
Date f-1,7
Signature of Applicant . ...............
A.
Agreement for.
Dated
Reviewed by:
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