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PROOF OF INSURANCE (2017 - 2018) CLOSED C CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDNYYY)
10/04/2017
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.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the pollcy(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 VERONICA FLORES
NAME:
Statefarm CRISTIAN AMAYA-STATE FARM P11ONE 4244775887 FAX 4242174988
IAF Ao..,")' INC.Nag:
882 W 9TH ST E-MAIL VERONICA.FLORES.FMZ4@STAT'EFARM.COM
14, -ADDRESS!SAN PEDRO CA 90731 MSURERfp)AFFORDING COVERAGE NAIL 0
INSURER A: State Farm Fire and Casualty Company 25143
INSURED INSURER B:
GERMAN DELGADO INSURER C:
DBA D.G ELITE AUTO DETAILING INSURER D:
1111 W F ST INSURER E:
WILMINGTON CA 90744 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.
1LTR"IIT ADDI.SUER POLICY EFF POLICY
TYPE OF INSURANCE INS POLICYNUMBER __1MMMP=1 JMMMD/yYYY1 LIMITS
COMMERCIAL GENERAL LIABILITY _EACH OCCURRENCE S 1,000,000
OWKOU-TO
P............
........,� � OCCUR .t Is1=$4�4E
NTED
CLAIMS-MADE 'I $ 300,000
MED EXP(Any one person) S 10,000
92-EF-K461-6 11/20/2016 11/20/2017 PERSONAL&ADV INJURY $
GENTAGGAFGA"I'LLIMITAPPLIESPER: GENERAL AGGREGATE S 2,000,000
POLICY
JECr
ODEDUCTIBLE
LOC ProPAGG = 5000 '000...,,,,,
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
_.. 1..a accrda_nt1
ANY AUTO BODILY INJURY(Per person) S
OWNED SCHEDULED
AUTOS ONLY AUTOS BODILY INJURY(Per accident) S
.,,,
HIRED NNON-OWNEDPROPt=RTY DAMAGE $
AUTOS ONLY AUTOS ONLY ..tr?p,ILII_tgNAanI1
S
UMBRELLA LIAR ��OCCUR EACH OCCURRENCE S
EXCESS LIAR CLAIMS-MADE AGGREGATE b
DEDI RETENTION$
WORKERS COMPENSATIONPER
LIABILITY
ANY PRROFFICEOPRIIETOR,ANI / ARTNERIL ECUTIVE YIN
N f A E,L.1EACH ACCIDENT OR $
(Mandatory In NH) E L.DISEASE-EA EMPLOYEE S
I}yes,describe under
DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached It more space Is required)
I
CERTIFICATE;HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
CITY OF EL SEGUNDO
AUTIYORI4ED RE ESENTATkVE
350 MAIN ST
EL SEGUNDO CA 90245
0
©1988-2015 ACORD CORPORATION. All " Its reserved.
ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD
1001466 132849.12 03-16-2016
TL Policy No. 92 EFK461 6 0984-FA34 CMP-4786 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
lic r:92 EFK461 6
Named Insured:
DELGADO, GERMAN
1111 W F ST
WILMINGTON CA 90744 5006
Name And Address Additional Insured Personr Organization-
CITY
r ai tion: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, any person or ment, the insurance provided to the
organization shown in the Schedule, but only additional insured will not be broader than
with respect to liability for "bodily injury", that which you are required by the contract
11 property damage"', or personal and advertis- or agreement to provide for such addition-
ing injury" caused, in whole or in part, by: al insured; and
a. Ongoing Operations
c. If the contract or agreement between you
(1) Your acts or omissions; or and the additional insured is governed by
(2) The acts or omissions of those acting California Civiil 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 your ongoing opera- which: '
tions for that additional insured; or
(1) Is allowed for the satisfaction of a de-
b. Products–Completed Operations fense or indemnity obligation by Cali-
"Your work" performed for that additional fornia Civil Code Section 2782 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.
©,Copyright,State Farm Mutual Automobile Insurance Company,2013
Includes copyrighted material of Insurance Services Office, Inc,with its permission,
CON'rINUED
CMP-4786,1
Page 2 of 2
2. Any insurance provided to the additional in- (3) The nature and location of any injury
sured shall only apply with respect to a claim or damage arising out of the "occur-
made or a "suit" brought for damages for rence" or offense;
which you are provided coverage. b. Tender the defense and indemnity of any
3. With respect to the insurance afforded to the claim or "suit" to us and to all other insur-
additional insured, the following is added to ers who may have insurance potentially
SECTION II—LIMITS OF INSURANCE: available to the additional insured; and
If coverage provided to the additional insured c. Agree to make available any other insur-
is required by contract or agreement, the most ance the additional insured has for de-
we will pay on behalf of the additional insured fense or damages for which we would
will be the lesser of the amount of insurance: provide coverage under SECTION II —
a. Required by the contract or agreement; or LIABILITY.
b. Available under the applicable Limits Of 5. With respect to the insurance afforded the ad-
Insurance shown in the Declarations. ditional insured, the following replaces SEC-
TION II —LIABILITY of Paragraph 7. Other
This endorsement shall not increase the ap- Insurance of SECTION I AND SECTION II —
plicable Limits Of Insurance shown in the COMMON POLICY CONDITIONS:
Declarations. a. This insurance is primary to and will not
4. With respect to the insurance afforded to the seek contribution from any other insurance
additional insured, the following is added to available to the additional insured, provided
Paragraph 3. Duties In The Event Of Occur- that the additional insured is a named in-
rence, Offense, Claim Or Suit of SECTION sured under such other insurance.
II—GENERAL CONDITIONS: b. Regardless of any agreement between
The additional insured must: you and the additional insured, this insur-
ance is excess over any other insurance
a. See to it that we are notified as soon as whether primary, excess, contingent or on
practicable of an "occurrence" or an of- any other basis for which the additional in-
fense which may result in a claim. To the sured has been added as an additional in-
extent possible, notice should include: sured on other policies.
(1) How, when and where the "occur- There will be no refund of premium in the event
rence" or offense took place; this endorsement is cancelled.
(2) The names and addresses of any in-
jured persons and witnesses; and All other policy provisions apply.
CMP-4786 1 1007033 148011 08-21-2014
©,Copyright,State Farm Mutual Automobile Insurance Company,2013
Includes copyrighted material of Insurance Services Office,Inc,with its permission
PCA
R1d a F'ARU'F 'I11F i1FFFF
Provdillq Ineurlllnce and Finl4ncidl Sorvicid
Fo 0"
Ift aiaA!dAA Tx r50054022
Attached as requested are your replacement insurance identification cards. If the attached cards are not accepted
by slow enforcement agency or your Department of Motor Vehicle office,please contact your agent to receive
additional assistance.
Thalnk you for choosing State Farm for your insurance needs.
------------------------------------------
IMPORTANT-IDENTIFICATION CARDS
STATE FARM
° I CALIFORNIA did AWOrm;
7NIi 0110 M11I7 III K[PT IN TNI ONUMD MOTOR
INSURANCE CARD VEMCLE FOR PRODUCTION UPON DEMAND
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From MvI Awarabollar howorafto II IF YOU HAVE AN AOCIO6IT-INOTIFY 711E POLICE IUMMMTrLLY
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TR 3M1 MdAKt FORD dUL'"'20'11 TO JAM M 1119 000I/1PTUAT ANY F1M►OF WOW AN' POiL1GK
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Xf:1Ww A I"AAD 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 THIS CARD.
ONE OOP/OF 14A 00#0 MIIro4A to 0E,C044110 .14NIE'Wr1�1�fil 11 Al At 1.?$011"A�1�NE 110""MAT'IIA'I4oft r�:E4'i4'1�A�x 1111111114,.E OF Ibt4ft"Wok"it Kt OO URL
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——————————————————————————————————————————
IMPORTANT-IDENTIFICATION CARDS
STATE FARM
I aIC .”arW'ul' CALIFORNIA ' �CDMUDTE1INTHI MOURI TOR
INSURANCE vA goDcO
� I . TSwwalAussi ubk lasorafo co my WTOY HAVE AM A JQ TNOIFY THE POLICE MML ,m
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POLCYNULBER ==W4 M-M EFFECTIVE POLOCT 1d CMWLUF NMPDMGDWMT
'WA �1 0AA14'1. FORD dUIIL022017 TO JAI111Z211118 DDAIf1f11r1�A1NpItIM►OItA7tR FOUOK
II V. F'I'SS Id'If1 1FT'2'F11T24IkA2'111III How In Ideff”your Conned,SM pClby to al nrni and damn"
ACXI14',1�''"V'AWw�I ld M If NUN 1 n A'I4� A 0.lir H tu.q n..d S.,A- u�C IW'mwlm�em,add�Au,W���"�d«'W'w�wmmll'�wi
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i Liebe S II1m.dN I4ar,Mw»mdn4�n��mxnum�mn a,�aup'
KEEP A CARO IN YOUR CAR.
THIS CARD 13 IRMID IF THE POLICY FOR WHICH IT WAS ISSUED LAPSES OR IS TERMINATED
KEEP YOUR CURRENT CARD UN11L THE EFFECTIVE DATE OF THIS CARD.
ONE OOR DF n00 0'01d'%MOM M.' 'E.D N4'�THt VIII AT ALL MUCSTHE FORIM SAT DIE WUAV AS EVIDENCE OF IN ;4"s NRI OOUM-
II OW CAM.47'11 A M40T OF A iC'A1A1;„WITH YOUR%11"CtE HIMMIN AT1ION RORWAL
14JM7 AMDdwn k wad odd& mm twwm and•w"and I.I dMVON4 Mrd. IANal1T
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:
U 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 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 the agreement with the City of EI Segundo is executed. My workers' compensation insurance
carrier and policy number are:
Carrier Policy Number Expiration Date
Name of Agent Phone#
(_2�) 1 certify that, in the performance of the work set forth in the agreement with the City of EI 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 th se pro isi Isr the agreement will automatically become void.
Signature of Applicant Date 11-6-17
p
Agreement for:
Dated: I—
Reviewed by:
1