PROOF OF INSURANCE (2018 - 2018) CLOSED A�1> CERTIF'ICAT'E O LIABILITY INSURANCE � DATEJ I�NYYY)
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.
IMPO'R'TANT,. If the certificate holder is an ADDITIONAL INSURED,the policy(les)must 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 The Small Business Team
I NSE:
Stratum Insurance Agency LLC PHONE 949-270-0609 P ):949-270-0608
P'
PO Box 273 RESSI team@st'raturninsurance.com
INSURERIS)AFFORDING COVERAGE NAIC
f Corona del Mar CA 92625 I INSURER A:Evanston Insurance Company 35378
INSURED
INSURER 8:
Maddlson Jade Halverson I INSURER c
DBA:Farm Friendz I INSURER D:
27725 Winding Way � —
Malibu,CA 90265 I INSURER E:
INSURER P:
COVERAGES CERTIF'ICA'TE 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.
M AR I TYPE of INSURANCE YO D "' ' , P LICY NUMBER 9-10-17 9-10-18 { LIMITS
POWCrNFF, P LICYEXP
OENERALWIStiJTY 3 I EACH OCCURRENCE $ 1,000,000
�UAMAUIZ IUNtNItu
X COMIMERCUIL GENEi�IABILr1Y VA4�" S 100,000
CLAIM34AADE x OCCUR D ExP(Any ori ) s 5,000
PERSONAL 6 ADV INJURY S 1,000,000
......-_.............".......... �GENERALAGGREGATE s 2,000,000
°�GEN"LAGGREGATELIMITAPPUESPER. PRODUCTS-COMPIOPAGG s Included
X 0 POLICY 7 P 7, F-1LOCi
AUTOMOBILE LIABILITY CO
MI1IdE INGLE LWR S
ANY AUTO BODILY INJURY(Per person) S
AUTOS AUTOSU�D I BODILY INJURY(Per soadent) S
HIRED AUTOS NON-OVMD PROPERTY DAMAGE AUTOS S
(Pr 1'q,
bb S
UMBRELLA Lt" OCCUR EACH OCCURRENCE S
�� EXCESS UAB �' CLAIMS-MADE I AGGREGATE >)
DED I l RETENTION S ;
WO,.KERS COMPENSATION WC STATU- OTH
AND EMPLOYERS'LIABILITY YIN R
ANY PROPRIETORIPARTNERIEXECUTIVE E.LEACH ACCIDENT i
OFFICERIMEMBER EXCLUDED? ED N I A
(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE,t
Ir yes dosc be under
We
OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S
i
DESCRIPTION OF OPERATIONS I LOCATIONS r VEHICLES(Attach ACORD 101,Additional Remarks schedule,N mora space N required)
Certificate holder is added as additional Insured per policy form CG2011 as required by written contract or agreement.
CERTIFICATE HOLDER CANCELLATION
. I
City of EI Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Attn:City Clerk THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
350 Main Street ACCORDANCE WITH THE POLICY PROVISIONS.
EI Segundo,CA.90245 1
AUTHORIZE.^.F,EPRRQEN ATI'V 1 I,
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1 4
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®1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD
POLICY NUMBER: 3EM6319 COMMERCIAL GENERAL LIABILITY
CG 20 110413
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - MANAGERS O
LESSORS OF PREMISES
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Designated Of Premises(Part Leased To You):
VARIOUS LOCATION
Name Of Person(s) Or Organization(s)(Additional Insured):
ANY PERSON OR ORGANIZATION AS REQUIRED BY WRITTEN CONTRACTOR TO BE
NAMED AS ADDITIONAL INSURED
Additional Premium: $ INCLUDED
Information required to complete this Schedule,if not shown above,will be shown in the Declarations.
A. Section II —Who Is An Insured is amended to 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
organization(s) 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 by This endorsement shall not increase the
law;and applicable Limits of Insurance shown in the
Declarations.
CG 20 110413 0 Insurance Services Office, Inc.,2012 Page 1 of 1
Evidence of Insurance FARMERS
State of California INSURANCE
Hanwid Halva-sonMaddlson PokyNUMbQr:19Sl22249
InvuriNI(s): Effective;0/9/2017
VNINMids: 2004 Dodge Truck Ram 2500 Crew C Pu Expiration;2/8/2019
4X4 Qu
VIN:3WK1.126C84G1141574 I
ReSbUrod HalverSonMaddlSon NAIC Number 21 5SZ
YourAgent:KtrAn N CioNvey
Ow"W(S)o
606U W 11,1005V AV 201
LosAngalaCA90045
A"ot Phots:(31 a)(A 1.2279
ratrrcrtre l'nwur.rrrcre E.m_.
4 1 I'll"N IN N11 j?GINI, oIN1,4to thi,CA ol'ou�00 kA•I kl jl IN
;,iib N 4 1 :4r N' ya Wf,f 0 111 l I W,�, "i,Ij
All IAV 1 Ne q 1 01;,0 y 4"', 1 lilyn 1w,I Ix1 0 6,I,,iq f
KEEPTH115 CERTIFICATE IN YOUR VEHICLE AT ALL TIMES.READ REVERSE FADE CAREFULLY.
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.
:affirm undor penalty of porjury under the laws of California one of the following declarations;
( _) I havv olid will rna,ntain a cuitificale of consent of self-insure for workers' compensation, issued by the Director
of industrial Relations as provided for by Labor Code §3700 for the porformnnco of tho work not forth thr.agmamcnt
with the City of EI 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 'he agreemen, with tho City of EI Segundu is executed, My workers' compensation rnsurancu
carrier and policy number are
Carrier Policy Number Expiration Date
Nan-.o of Agent Phonc#
( ) I certify that. in the per frac mance: of the work set forth in the agreement with the City of EI Segundo, I will not
omploy any porson .n any manner so as to become subject to tho workers' compensation laws of Cauumia, and
ngrc•;e [flat. if I should become subject to the workers' compensation provisions of Laboi Code § 3700 1 must
immediately comply with those vrry kions,nr the will automatically become void
Signature of Applicant ' 't � Date
M�
Agreement for:
Dated: �_ ...,...
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Reviewed by° l
1