PROOF OF INSURANCE (2019) CLOSEDPRODUCER
CRUSBERG-DECKER INS SERVS 044523 HC 09
285 N HILL AVE STE 200
PASADENA, CA 91106-
TELEPHONE:(626) 585-1491
POLICY NUMBER ; POLICY PERIOD
0401 09 170135150 jFRROMQ2J26/201812-01AMTa02126/201912r01AM
PERSONS "INSP. VID
REBECCA LOWRY
DRIVERS
REBECCA LOWRY
RMNAM E R C U RY AUTOMOBILE POLICY DECLARATIONS
INSURANCE COMPANY IMPORTANT COVERAGE EXCLUSION{
APPLICABLE TO ALL COVERAGES,, INCLUDING RU"r NOT LIMITED "'f O. LlABILiTY
ANt1 UNINSURED MOT0'RMS, PROVIDED NOW OR LATTER.
R is agreed that the ins,urancc TTlforded by 1hIS Duca
Txtrlalt a1JY ap a1 aala usccTures ko ITT ITTTra rit a .Ira °tarMa�rar any
ILIA pDrty G IN"0'kI'tea aaay awlarlo� whrlwa�le TS iacuh�Ey lased ar
rapaaa -rtlarl tag. Ta IN r I.�rr Ilsfc d iaaalTaa+a ra y1�Trdl�s.� �1f LYTTfirtK: tlaln
Ix r Txap r 17ra emx"awkl�xluer TS1sr pax T Para � I,Ieahst� clTiv� I. ..
.M..A.m..I..L_..I.N..G__., P.S B.OX ...
,.
—, ......
ADDRESS JOSHUA TREE, .......... ., ,, ..., .,,. ... .. " ...,��,,, , ......_ ,.
CA 92252
DAR YEAR
1 2002 MAZDA MX-5"MIATA CONV 2DR JMINB353720231842 N. 10/2002
2 2010 SCION XB UTL 40R JTLZE4FE8A1099718 U 0212012
CAR �RASS LOPAYEES IL%, ADDInORAL INTERESTS (AIT, LOSS PAYEES AND ADWThViAL INTERESTS ADDRESSES . GARAOBTC ADDES ICAND REGISTERED OWNERS RD) OMER THAN TNOW LISTED ABOVE
1 GA 6646 QUAIL SPRINGS AVE TWENTYNINE PALMS CA 92277
2 GA 6646 QUAIL SPRINGS AVE TWENTYNINE PALMS CA 92277
Coverage applies only if premium charge is listed below. Coverage/Limits are subject to all policy terms
ELWB�17LiTY
. OFDUCTIBLECAR1 $1,000
CAR2 $1,000 CAR $
PREMIUMS
54
.,.,.�,"_.... m. .,. .e..._..»...,
NON -FACTORY EQUIPMENT
BODILY INJURY
$100,000
HIRSDNO$3 f 000 EACH
166
96
CAR,.�
ITEMS INSURED AND A610UNTS OF
WSURANCE FOR EACH ITEM ARE STATED
PROPERTY DAMAGE LIABILITY
$100,000
FACHACGDENT
112
182 !:
''HEREIN.,. ITEMS INSURED ARE SUBJECT TO
UNINSURED MOTORISTS
BODILY INJURY LIABILITY
$100,000
i
EACHPEReoIr $ 300,000 EACH ACCIDENT
32
7O
686
THE DEDUCTIBLE,
UNINSURED MOTORISTSCPR
S
MAXIMUM
�
Po�ucw^ I=aµE
Sy
I}
PROPERTY DAMAGE LIABILITY
. OFDUCTIBLECAR1 $1,000
CAR2 $1,000 CAR $
COLLISION DEDUCTIBLE WAIVER
54
.,.,.�,"_.... m. .,. .e..._..»...,
COLLISION........
MEDICAL EXPENSE
$1,000
( 6 10
LEASETLOAN GAP COVERAGE
CAR CAR CAR
CARL $75
REPAIR OR REPLACEMENT
CAR CAR CAR
4
COST COVERAGE
$ PER DAY DAYS
I
GO-MPRT:.HENSSVE, �. �...........
. OFDUCTIBLECAR1 $1,000
CAR2 $1,000 CAR $
.0 ,....., 100
54
.,.,.�,"_.... m. .,. .e..._..»...,
COLLISION........
owucnSLEGAR1$1,000..
CAR2$1,000...C.AR. $,.........�
2'._�.,".
58
256
ROSIDE ASSIST
PERADOCCURRENCEANCE
CARL $75
CAR2 $75 CAR
4
4
RENTAL CAR BENEFR
$ PER DAY DAYS
SNDORSEMENTSATTACHED TOTHE POLICY
� M PREaap'D,vasPRCAR
U-10 0612016
686
760
�
Po�ucw^ I=aµE
IMPORTANT INFORMATION
TOTAL PREMIUM 1,469.,52
EFFECTIVE 02/26/2018
The enclosed Auto Insurance Renewal Sill and the U251 IMPORTANT NOTICE are part of this policy. These
specify the amount of your premium, your payment options, any applicable fees, and the due date.
Your automobile insurance expires and coverage ceases at 12:01AM on 02/26/2018. Coverage under
this policy will become effective provided you pay the premium and any applicable fees as indicated
on the Auto Insurance Renewal Bill. If you have any questions, please contact your agent or broker at
the phone number provided above.
? MAILED TO:
REBECCA LOWRY
PO BOX 125
JOSHUA TREE, CA 92252
.." .� � _...._.�.. ..-.... a ,.w ...
NSURED COPY
POLICY NUMBER: 0401 09 170135150
MAILING DATE.: 01/26/2018
11
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:
(_j I have and will maintain a certificate of consent of self4nsure 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,
U I have and witl maintain workers' compensation insurance as required by Labor Code § 3700 forthe 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
Name of Agent
Policy Number Expiration Date
Phone #
I certify that, in the performance of the work set forth in the agreement with the City of EI Segundo, I will not
=ploy 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 a rkers' compensation provisions of Labor Code § 3700 p must
immediately comply with those provislo agreement will automatically become void.
Signature of
Print Name
Agreement for:�e,,
M �OW6A' '-W
Dated:
Reviewed by.
w
Date --Qet za S