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PROOF OF INSURANCE (2019) CLOSED .oR OF LIABILITY INSURANCE DATE(MMIDDrYYYY) CERTIFICATE 06/18/20181-.-.-1 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY A�N�D ......r..._.,.�,..�.,..,..,. _W_ ...... OCONFERS 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 O115iURFC1,,the pollcy(los) must have AIDDl`t'IONAL INSURED provisions or be andorsed, If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificato doe's not confer rights to the certificate holder In(leu of such o'nclorsoment(s). ( t T))KrOU iI sura Place, Unit , PH rqok J8181fitbKr r PRODUCER nwt -- nyon (, tlr° E. N4tcJltFNrs Nlt.�tdrance Services, Inc, IwplyNt , tl ( )+ IAPB,Not (818)407. 5308 Ghzilswodh,C A 91311 Ar'Ins'1r;ss. "Ir la;arr'od,r�ttlr�Ic;l(�i?N,rotys'rrans.com IIN341Rd'.N'(5)AFFORDING COVERAGE NAI'�r'.m Phone No.(818)407-5300 Fax No.(818)407-5308 INSI ACA A: NAS-North AtC,ericaan Specially Insurance Company, 2'IM741 INSURED INSt9NRt',tltV# EL SEGUNDO ART WALK, LLC 763 MAIN STREET INSURERC; EI Segundo, CA 90245 INSURER D: INSURER C. ._......'804-1,014 Fox Noy INFar;w RFR w" t'�i7cnraND.d�13.. �.. .w ..., CERTIFICATE NUMBER:75921...... .. ^ ...�...� COTHI VERAGES ATO CERTIFY CICS OF wNSURANCE LISTED BEL WU _ HC wN5URE0 NAMED ABOVE ER" OD NDC TED. NOTW THSTANDING AN..w.w......,....„„.IRE TERM OR COND TION OFBANY CONTRACT OR OTHER OCUIMEONtT W THiIREO PECT TOLWHICH TIHIS POLI Y REQUIREMENT„ CERTIFICA'I"II MAY BE (ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED Hr;REIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN'mPi „(1Nn VrNtrl NufptY wPptM 4'u9t7RYL'M YIYr LIMITS NA; X CO. """"TYPEOr INSURANCE EKG8022500-00 0610112018 6/01/2019 EACHCOMMERCIAL OCCURRENCE CLAIMS-NlADE I X�OCCUR X �( Cr74Mx tt r.IY°.Y lip IJYI',1u - wirdr~„r.Sd.�:,;r;,nr,.wmr,,; s 1tt(1,l)t„IQD, X -----Dost Liquor MED FXP(Any one --- q ( , 0 _AggA0 )— ' Full Li UOr 1,000 000 A /OCC I'.�;o'fir,^rr,re�u �ADV INJURY ' r I ()0(,t,1t)14aC) GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE S __ 009,—GOO' POLICY �PRO- — r JECT _J LOC PRODUCTS-COMP/OP AGG S 1,000,000 NAS Aur ANOiBC 14Et.IA.B...ILITY ....................... ...I .. E KA80O2279-QD 01101/2018_0fi011/2019�dry ..,. VIrzS .._.�1ww, w00...0...,.0..0.„..0 AUTO BODILY INJURY(Per Person) .., Included OWNEDr SCHEDULEDAUTOS ONLY BODILY INJURY 'G'. AUTOS VIVd�61Ur E'•_g�tllrr r,lp ur"r,r.ra rJ„,Irl Included X. AUTOS ONLY X AUTOS ONLY (Par ''rtlanl 5 HIRED '�, NON�OWNti] , o acc D NA';j UMB8 RELLA UA l X 'OCCUR EKX8004000.00 56.76T'/2018;06/0112019 E%CESSLIA )(1tr X� B., . . .l CLAIMS•MAUE AGGREGATEw11VYp4; S 1',Q'Ot't,t`fO(a, ,., i t1r.Ttl:Fk^rar'wkd S ...., y .. ...,.... ..�..............._s,M1 WORKERS COMPENSATION .,-,...Y.....— ........., ___ __ .., ._..___.. I^Nw..............'"_..Y.,,,11.,.1: AN�YPROP R ETOR(P RTNERD? ❑ N l A .,.,.,.•. E L EACH. fry AND EMPLOYE 0 ' IN IA FUPARTNER/EXECUTIVE ACCIDENT S 04 y in d111 Ufm.w,rrtNrscaRlEL DISEASE-EA Ml'+d r,,uYC'd`.', 5 y n Vr�w,Oliw i R?rr'VIG:rp.;'N.w�,'......." E L rrN:dW,^..C,...,N�N,wI u4".Y I N!'�uuw $ Inland Marine EKN8004768-00 06/01/2018 06/01/20191 SeeA,V'lachcxl' `DESCRIPTION... IvEHES OF OPERATIONS I LOCATIONfi ICL ........ .._-,.„,.......„............. Coverago Location: United SI ._.. .. .w.,.,,, g ales&Canada Covered Events As Declared to and Accepted t:r':rrillit;stP holder is named as additional insured and loss payee as their interest may appear. Coverage by Carrier Is primary and non•conlribulary. All coverages expire at 12:01 a.m.Standard Time, liwcr rtC,4wrnX ravurwX rtlraifus m rV tut`I'I4,111tell'.l"l y ur w4r lh ,�I;tl'rw;rriui d EvorN 11 rrrr'"Ll t lura,tl lcu APrI:'s a,a�rtdllr aatl ._ t d ... _ _ CERTIFICATE HOLDER CANCt tMI,ATION _. „...."..m_ ........ CITY OF EL SEGUNDO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ATTN: OFFICERS, OFFICIALS,AGENTS AND THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN EMPLOYEES ACCORDANCE WITH THE POLICY PROVISIONS, 350 MAIN STREET EL SEGUNDO, CA 90245 United States Of America - AUTHORIZED REPRESENTATIVE e Phone No. 1 Fax No. � •...............WW_.. 1988.2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD This certificate of insurance does not affirmatively or negatively amend,exiend,or alter the coverage aflorded by the insurance policy POLICY NUMBER: EKG8022500'00 COMMERCIAL GENERAL LIABILITY CG 20110413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ 0[ CAREFULLY. ��U�U�Kl78��U INSURED �� &�� uno��o��~ on�w��u�� u�n��nm�n��~"�� "� 8 ��A�� A��N�U�� "�m�� "�" ou��x�on�� This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE __ ________ Designation OfPremises(Part Leased ToYuu): CITY OF EL SEGUN[J{} OFFICERS, OFFICIALS, AGENTS AND EMPLOYEES, 350 MAIN STREET EL SEGUN[}[) C/\ 90245 � _....__.... _' Name Of Pwn,un(s)orOrQwn|zot|mn(s)(Additional Insured), CITY OF ELSEGUNQC) OFFICERS, OFFICIALS, AGENTS AND EMPLOYEES, 350 MAIN STREET EL SEGUNQ{) CA 00245 Additional Premium: $Included | nfurmaUonrm%�Iired toummp|e/m thio_Snhedute. |[not shown . will he shown in the Doo|aru/;oms, A. Section U — VVhm Is An Insured is amended to 2. If coverage provided to the additional insured include as an additional inuu,od the pemon(s) ur is required by a contract or m�reamen\, the organization(s) shown in the Schedule, but only Insurance afforded N such additional insured idhpmnt to liability uh �8 aout of the will not be broader than that which you are ownership, maintenance or use nfthat part of the required by the contract or agreement to premises |omsad 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 |nsvrada, the following is added to This insurance does not apply to; Section III—Limits Of Insurance: 1. Any "uuou,mnow^ which takes place after you If coverage provided to the additional Insured is cease hobuatenant|nthat premises. required byacontract oragreement, dhemoa\we 2' Structural alterations, new construction o/ will pay on behalf ofthe additional insured Is the demolition operations performedomoun1of|nouranon', orm�� by or on � 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 Um|(u of However: Insurance shown\nthe Declarations; 1. The Insurance afforded to such additional whichever|mless. insured only applies to the extent permitted This endorsement shall not increase the bylaw, and applicable Limits of Insurance shown in the Declarations. C<32¢ 11 041J @ Insurance Services Office, |nc.. 2D12 Page of DATE(MMOMY) ADDITIONAL COVERAGE DETAILS 06118/201 B ...................... INSURED EL SEGUNDO ART WALK, LLC The following Is attached to and made part of certificate number 759210, Policy Details Coverage Limit Deductible Inland Marine Company: North American Specialty Insurance Company Policy Number: EKN8004788-00 Period: 0610112018-0610112019:365 Day(s) Equipment.props,sets,wardrobe(rented} Excluded Equipment,Props,Sets,Wardrobe(owned) Excluded Rented Furs,Jewelry,Art&Antiques Coverage Excluded Extra Expense Excluded Third Party Property Damage 1,000,000 2,5010 Office Contents Excluded Business Income/Extra Expense Excluded Hired/Non-Owned Physical Damage-Aggregate Excluded Hired/Non-Owned Physical Damage-Per Vehicle Excluded Rental Cost Reimbursement Excluded EDP EDP(Electronic Data Processing Equipment) Excluded Limited Computer Virus Coverage Excluded Accounts Receivable Excluded Valuable Papers and Records Excluded Money&Securities Excluded Waiver of Subrogation Excluded Coverage Extension Endorsement Coverage Extension Endorsement Excluded Worldwide Coverage Excluded Terrorism Included General Liability Company: North American Specialty Insurance Company Polley Number: EKG8022500-00 *Period: 06/0112018-06/01/2019,365 Day(s) General Aggregate 2,000,000 Products/Completed Operations 1,13013,000 Personal I Advertising Injury 1,000,000 Each Occurrence 1,000,000 Fire Legal 100,000 Medical Payments 5,000 Blanket Additional Insureds(other than clly/special carts IS Included waivers) City Y Other Special Certificates Included Waiver of Subrogation Included Employee Benefits Liability-Policy Aggregate Excluded Employee Benefits Liability-Each Claim Excluded Host Liquor Included Liquor Liability-Aggregate 1,000,000 Liquor Liability-Each Common Cause Limit 1,000,000 Abuse&Molestation-Aggregate Excluded .............. ............ CERT- ------- APM- DETAILS 1009 Certificate Number 759210 .......... Polle I y Details Coverage Limit Deductible, Abuse&Mole sta lion-Each Claim ExrJuded Terrorism Included �Att ooverages expire at 12;01 a.m.Standard Time, APM-CERT-DETAILS 1009 Cerlificako,Number 759210 Scheduled Events Certificate Number:759207 EvennttTypo Venue Dates Attendees ..... � U ,,..,.,....,,,.._ EL,� 4sL1hlE)t?AST PARKING LOT 0612012018-06P21/2018 at 12:01 am(Sehep) 50 Participants WALK 201 a 314 MAIN STREE'1 06/21/2018-061221201 Bat 12:01 am 1,000 Spectators Ar$Shows FL.SEGUNDO,DA 90245 ABANEV-SCHO((1 36) gage 1 of 1 Scheduled Events Certificate Number: 759211 Event Type Vonue Dates Attendees EL.SEGUNDO ART PARKING LOT 0711812018-07(19/2018 at 12:01 am(Setup) 50 Partidpants WALK 2018 314 MAIN STREET 0711912016-07120/2018a@ 1'1:01am 1,000 Spectators Art Shows EL SEC3UNDO,CA 90245 ABANEV-SCHD(OB/06) Page 1 of I Scheduled Events Certificate Number: 759210 Event Type Venue Dates Attendees EL SEGUNDO ART PARKING LOT 080,512018,,06/1612018 al 12�01 ani(Setup) 50 Participants WALK 2018 314 MAIN STREET 013116/2018-08117{2G14 at 12,01 am 1,000 Spectators Arl Shows EL SEGUNDO,CA 90245 ABANEV-SC Ht)(05106) Page I of 1 l i L i PA Y 43 Orr'r SCHEDULE OF FORMS tai opst�t .................... lnsjdrad: EL SEGUNDO ART WALK,LLC,' This S&iedule of Forms Is attached to and inside part Of certificate number 75921 O,as of 06/18/2018 at 11:59 AM P1,and lists the form,.Included In the pothry(s) and subsequent endorsement(a)at the time this carfificale was issued. Ed. Name ............ Inland Marina Policy Inland Marine Notices SP5359 0514 5wis3Rc Front Jacket NAS-GLB-NOTICE 0901 Privacy Notice and Disclosure Flainhas NAF-ABIM-DEC 0808 Commenzal Inland Manno Declarations NAS-ABF-SCH 0608 Schedule of Forms NAS-NI-SCH 0101 Named Insured Sdiedulis NJAS,I-S�EXT 0101 Wc.,fliori Schedule NAS-AB-CPC 1008 Common Conditions,Dalinijons and Exclusions NA&A87PD-POL 0608 Third Party Property 0,wriago Coverage Form NAS-AB-003 0008 Minimum Premium Eodnvsrmncnl NAS-AD-725 0606 Lci*,ti Payable form NAS,NFI.711 1109 Excluded Property Endorsery-oarill CLUtB2 0116 Amendalm Endorsement-California IM2009 0112 Amendatory Endorsement-California CLO600 0115 Qediried Terrorism Lose SP4161 Oils Exclusion of other than Certified Acts OPTenormm SP6069 0116 DiRd".ore pursuant to TRIA SP5694 1012 litlernationRl Trade or Economic Sanctions SP3881 0307 Signature Page Liability Policy Generall 1-fabilo Notices SP5369 01"14 SwissRe Front Jacket NA&GI-B-NOTICE 0!110i Privacy Nolice and 0[scloskire Forms NAS-AF3GL-DEC 0109 Commerdal General Liability Declarations NAS-ABF-BCH 0609 5ichediAr of Forms NAS-NI-SCH 0101 Named m1wrird Schedule NAS-LS-EXT 0101 Location Schecitile NAS-AB-220 0611 Annual Event Rating Ichrmulc NAS-AB-214 0613 ConcesimonairelExhibilor Role Endorsement NAS-AB-219 0613 Additional Insured Poling Schedule NAS-AB-007 0909 Schedule of Events C00001 0413 Commercial General LPiribihly Coverage Form IL0017 1198 Common Policy Conditions IIAS-AB-003 0608 Minimum Premium Endor5rmant IIAS-AB-416 0608 Event Limitation Endorsement NAS-AB-432 0600 Employee Defined NAB-AB-430 015061 Communicable Disease Exclusion lAA$-A5-41I 0608 Unscheduled Products Llinilallon Endorsement NA-,AB-402 0908 Additional Insured-Owners or Lessees,Scheduled Person or Organization(Primary and Noncontributory endorsement) CG201 t 0413 Additional Insured-Managers of Lessors of Premises CG2001 0413 Primary and Noncontributory-Other Insurance Condition CG2012 0413 Additional Insured-State or Governmental Agency or Subdivision or Political Subdivision-Permits or Authorizations CG2025 0413 Additional Insured-Lessor of leased equipment CG2026 041.1 Additional Insured-Designated Person or Organization CO2013 0413 Addilionpi Insured-State or Governmental Agency or Subdivision or Political Subdivision-Perrilils of Aulhod rations Relating to Premises CG2404 0509 Waiver of Transfer of Rights of Recovery Against Others to Us NAS-AB-006 0608 Unscheduled Produclion,Presentation or Event Exclusion NAS-AS-600 0608 Producklort Blunt,Pyrotechnic&Animal Exposure Exclusion NAS-AB-417 0608 Hazardous Acilvitles,Pyrotechnic&Animal Exposure Exclusion NAS-AB-205 0608 Newly Acquired or Formed Enlily Exclusion NAF,-AU-420 ofifie Partnership,Joint Venture and Limited Liability Company Exclusion CG2147 1207 Employment Related PracliceS Exclusion NAS-AF3433 0909 Gross Suits Exclusion NAS-AB-200 0608 Property Damage to Ranted Premi%es Exclusion NAS-AB-434 0606 False AuLsi,Dulendon,Inipneonment,Libel,Slander,Right to Privacy,Advertising Idea,Copyright,'Trade Dress and Slogan Exclusion NAS-AB-404 0608 Infornialional Corherif Exclusion NAS-AB-426 0608 Media Content Erirlvsion NAS-AB-405 0608 Injury to Participants in Sports or Athletics AL11011es EXClUsion NA5-AB-4'10 0608 Rep and Hip-Hop Conditional Exclusion NAS-AS-408 060® Moshing Exclusion NAG-AB-419 0608 Overnight,Outdoor And Temporary SiftiClure Camping Conditional Exclusion NAS-AB-424 0608 Abuse or Sexual Molestation Exclusion NAS-AB-403 0909 Assault and baltery Exclusion Al 1A,CJ"'T.FDRMLIST Hi 4 Cerlificalo Nurnber:759210 Page 1 of 3 DA7E(MMIDIVI)n SCHEDULE OF FORMS 0611812018 ..w_—------ --- Insureida F-,L SEGUNDO ART WALK,LLC This Schedl.112 QfForrns is attached to and made part ofeerlificate rfurnber759210.as&06,11812018 it'11:59 AM PT and lists thn forms Included to the policy(s) and subsequent andorservient(s)at the(into this certificate was issued. Foran# Ed. Name NAS-bB NAS-AB-d23 0608 Ab5oluIr Asbestos Excluision NAS-AB-425 0600 Lead Contamination Exciudon NAS-AB-428 0608 Fungus,Mildew and Moto Exclusion 002190 o3o5 Silica of Silica-Belated Dux(FxrAumrin NAS-ABLL-DEC 0608 Liquor Liability Declarations 060033 04,13 Liquor Liability Cowt,,ragtt Form NAS-AB-221 0613 Liquar Rating.'Whedule IL0270 0912 California Changes•Caoiccilillon and Nonrenewal Endnr'xemrgll 10021 09oll Nuclear Energy Loffbility Exdusion Endorsement(Broad Form) C0,5234 0105 California Changes SP4159 0115 Fyclitrion of other than Qejillf.,d Acts F,P600 0115 Dirdusure pursuant In TRIA 002170 0115 f;arc on Losses From Corfifid Acfiq of Tierraruirn SPS694 1012 InIcrnaluonst Trade or Ecanouvc 5-Inclions SP3881 0307 519niloul Pagan Autonnobiie Pohcy Autorriolalle Notices SP5360 0514 SwistiRe Front Jacktil NAS-OLB,NOTWE 0361 fonvmcy Notice and Disclosure Forms NAS-NG3-MCA-r)EC1 0201 Buslnos6 Auto rovpraSt,.Frifin Declarations NAS-CA-DFC2010l Schedule of Hired at BofrQwrd Covered Autos Goveragf find Prorniurrs NAS-ABF-SCH 0608 Schedule of Forms NAS-Nf-S(.',H 0',01 Named Insuited Schedule NAS-LS-EX r 0109 Location Scheduhr CA0001 loll Business Auto Coverage,Feint IL0017 1198 Common Policy Condolont NAS-AB-003 OG08 Minimum Prerliurn Endonrornent INAS-AU-900 0608 Additional fi,tmiiti9�rlwnris or LossocS,Sclijeduled Damnn or Organization NAS-Alf-00 0608 Additional fiouied-Gvdnarfi or LanEeeIi,Scheduled Per.snn Pr Organization(Primary Non-Conitibulory Frirlorsoment) NAS-AB-D02 n6off %Vawei of Sulbtr"Judi"" 11-0270 oq12 California Chengeq-Cancellation and Nonrenewal Erldorttemeot 10971 0938 Nucicar Energy Liability Exclimon Endorsornerit(Broad Portae) CAD 143 1013 California Change.,, SPS694 1012 Internmrional Trade or Economic Sancitona SP3881 0307 SianWure Pag& Excess Liability Policy Excess Liallolilly Notices SPS369 0514 SlvissFre Front Jacket NAS-GILB-NOTICE 0901 Privacy Notice and Disdorure Forms FF00001 0712 Following Form Commercial Fxcefrf;Liobility Insurance Policy ilackollions FFQD135 0712 Narrind Inituicd Schedule FF00127 0712 Following Form Commercial Fvces&1,uohfIrly Insurance Policy FFo0171 b315 Multiple Followed Policy ArtropoWslory I imiorsernont FF00118 0712 Non,,i ollow Form of Specified Coverage fit FoUnwod Policy FF0009B 0712 Lewhi f:Yd'"1Dn rF,00097 0712 SlftS Exclusion FF00011GA 0712 California Changes-Cancellation and Nonrenewal SP663Z 0115 Effdrrsirrr of Other Than Certified Arts of Torronn, SF36060 0115 DiRcioeure purrvont to TRIA SP5629 0:l G Cap on Loss"from Cvil;frad AM a'Te,fDrikm SPS694 1012 InjernBhonal Trade or Economic Sancnon& SP3881 tLW7 Signature Page APA�GERT-FORVLIST OV14 Certificate Numoct 759210 Page 2 of 3 SCHEDULE OF FORMS 06/1 B1201 a Unuli ond Schedule of Forms in elkcl Fin of 06MlftiW)Ae at 11;5t)A%l FIT,N.drips not offipwativelV or naipitmMy amond cstend,Pt Wtv IfIc affi,,drif by ah e mwroiwr:po'Prq nor confer any fiqMs upin fhe rerliRmo holder.You way be reclufted to njuelt rin updWed M n1P nw(101 f,4 roolVILIP01011N, [he iWvrwatmn mcfuded of 0,1,"cr'd;6vue mm Inv.ttf9vn provided by$Onw"�'iTlrPi"lee tion:w% 'r fnrynLv ordy aw ,k'es no, a 4:'Ofiil+Q1 hclwrfrlh the'!r4 20Wicmv 11(flucc or iiny O'Niumd and AbfXiM IWtwM1C"Btoi'et, Hy au opong ops cflirifa�'110 hlAdef pms AW(ut affil, oI:nf��it,I In!Pit['a I Cqi I(.!tim k V!I i I I Cato�t��Iow Of w I-,!ov.I;rod,tO ii.�-I00Y ibr'i)fjvnI*f 11,I,i��tr I r,amcr�,5� A �'u I rw�t' I na i:w�I a ferfeno I It atwc n wh410;f7f"I e CeJvetlllm.'Wcid hwnil ko 1950,coIWpcl",h0dti�ei,t 41111y 041% and Ieview the Imled qtcenjbgjI,i:o ynur n V'kr'V iI10 1 0914 Gediricato Nurnbev 759210 Page 3 of 3 .......... Dsuj MMAAX.,NeYY� Certificate Verification 06/18/2018 Insured® EL SEGUNDO ART WALK, LLC Abacus provides an efficient website lookup tool for certificate holders to verify the authenticity of certificates of insurance. 1. Navigate to the website and input the verification code OR Scan the QR code, 2, The actual certificate issued through the Abacus Platform will download. 3. Compare the details of the downloaded certificate to the certificate presented by the client. WebsIta Verification Code www.abacu!s,not/verify-certificate OFOPG29QT6 About Certificates Issued through the Abacus.net Platform 0 Abacus requires that all certificates be issued through the Abacus Platform. Certificates issued outside of the Abacus Platform are invalid ® Certificates may be issued through the Abacus Platform by either the named insured(if registered through the Abacus Platform)or their Abacus registered insurance broker. ® Certificates with any stray marks,cross MRS or alterations of any sort are invalid. 9 Each certificate is numbered and correlates to the document issued through the Abacus Platform, MINiniDw mw,Oa 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 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# (_X) I 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 those provisions or the agreement will automatically become void. Signature of Applicant Date 6-19-18 Print Name /J'O n McCulloug Agreement for: Lv--� - P5,)N -1A Dated: Reviewed by: ,, � .� .,� .,