PROOF OF INSURANCE (2019) CLOSED CDATE(MM/DD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE 10/09/2018
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOTAFFIRMATIVELY OR NEGATIVELY
AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF I NSURANCE 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 policy(ies)must have ADDITIONAL INSURED provisions or be endorsed.If SUBROGATION IS WAIVED,subject
to the terms
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). �^q
PRODUCER CONTACTMY � \1.I
NAME: JENNIFER ALVAREZM1ti
JENNIFER ALVAREZ INSURANCE AGENCY PHONE FAX
211 S.CITRUS AVENUE (A/C,NO,EXT):626 339-6800 (A/C,No):626 608-3700
COVINA,CA 91723 E-MAIL
ADDRESS: JALVAREZ@FARMERSAGENT COM
INSURER(S)AFFORDING COVERAGE NAIC#
INSURED INSURER A: FARMERS INSURANCE CO
INSURER B: SCOTTSDALE INSURANCE CO
COLE STERNBERG
INSURER C:
1850 INDUSTRIAL STREET,UNIT#506
INSURER D:
LOS ANGELES,CA 90021
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
'T"I II.S IST(::)C.LR'TIFY n IAr rl II POI.ICIFS,OF II'SURANC Ir I ISrED LIEL(DW IIAVI-hI+N ISSUFI)FO Ti II'IN'SL)RI.D NAMF"AI RVI FOR FI If-POLICY III RIOD INDIC:A'I I D NOTWITI ISTANDINGANY
RI QUIN MLIN1,'rERM OR CONEA'TION OF ANY C'ONTRACA OR OTI Ir.t D(DCUIVIFN r WI I Ii RFSIM CT FO VVI IIG I"ri IS C'ERTIHCAI I MAY III ISSUI-I)OR MAY 1'I-It[AIN,I III IN.SURANC:EAl'-rORDID BY rl Ih
''(")IIt::Ir...`.wDC::`:;CIYII'iI:,C7111,RIIN1�1vU1§�I-Cl FOALLFHI IT RIMS.EXCLUSIONS AN 1)CON DI T K)NS OF SUC I I PO LICI FS LIMITSSIHOWNIMAYI-AVI III INRI DUCIDBYI'AIDC',LAIM
INSR TYPE OF INSURANCE ADDTL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS
LTR INSD WVD (MM/DD/YYYY) (MM/DD/YYYY)
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE X OCCUR I)AMAGI TORI N'I't I:) $
IIRI-IVIISI-S(Fa Occ.unren`:ol 100,000
. MI-DIXP(Anyoncl:rerronl $ 5,000
B Y N OYAQW-J 10/09/2018 10/09/2019 PERSONAL&ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMITAPPLIES PER: $ 2,000,000
110I ICY PROJECT LOC PRODUCTS-COMP,OPAGG $ 2,000,000
AUTOMOBILE LIABILITY $
CC?MI;IIVI I)51N(.;LE L.IWII I
a ccidel,10
ANYAI.110 BODILY IN.11JIFY(Per porson) $ 250.000
A OWNEDAUTES X SCHEDULED BODILY INJURY(Per,cc�idcnl)$ 500,000'
Y N 194463362 08/31/2018 08/31/2019
HIRED AUTOS NON-OWNED PROPERTY DAMAGE
ONLY AUTOS ONLY (PorocddenQ $ 100,000
$
UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000
X
A EXCESS LIAB CLAIMS MADE Y N 606033963 10/09/2018 10/09/2019 AGGREGATE $ 2,000,000
DED RETENTION$ $
WORKERS COMPENSATION PER OTHER $
AND EMPLOYERS'LIABILITY STATUTE
ANY PROPRIETOR,PARTNER/ Y/N EL EACH ACCIDENT '$
EXECUTIVE OFFICER,`MEMBER N/A
EXCLUDED?(Mandatory inNH)
EL DISEASE-EA EMPLOYEE
If yes,describe under DESCRIPTION OF
OPERATIONS below I.L C)L'Sf A:41 I'ELICV"Lllvlll :b
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
2017 Audi A7 Quatt VIN#WAUW2AFC2HN064693 Schedule Vehicle with 250/500/100 limits with excess umbrella coverage of 1,000,000 combines single limit.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORETHE EXPIRATION
City of EI Segundo DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.
350 Main St AUTHORIZED REPRESENTATIVE Jennifer Alvarez-Agent
EI Segundo„CA 90245
ACORD 25(2016/03) @1988-2015 ACORD CORPORATION.All Rights Reserved
1-1759 1 1-15 The ACORD name and logo are registered marks of ACORD
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:
IJ 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.
U 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#
q0 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 o the a,gre ill automatically become void.
� Signature of Applicant
Date
Print Name
Agreement for.
w '
Dated: ®E�
Reviewed by: