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PROOF OF INSURANCE (2020) CLOSED'R'' DATE (MM/DD/YY" CERTIFICATE OF LIABILITY INSURANCE 08/19/2019 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 policy(iss) 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($). ... ., . „ ., PRODUCER CONTACT .,.,.. pH0 E FAX MARSH RISK &INSURANCE SERVICES TT" 345 CALIFORNIA STREET, SUITE 1300 �Af�bla.E>H _._.._21ju <UPI' CALIFORNIA LICENSE NO. 0437153 E MA L SAN FRANCISCO, CA 94104 App Attn: sanfrancisco.certs@marsh corn CN 101346861-STND-GAWU-19-20 INSURER(_S) AFFORDING COVERAGE NAIC N INSURER A: Travelers Property mCasualt Com anY Of America 25674 INSURED THE MOST WORSHIPFUL GRAND LODGE OF FREE INSURERS: . AND ACCEPTED MASONS OF THE STATE OF CALIFORNIA INSURER C ATTN: KHALIL SWEIDY INSURER D 1111 CALIFORNIA STREET " SAN FRANCISCO, CA 94108 INSURER E; INSURER F; COVERAGES CERTIFICATE NUMBER: SEA -003626586-02 REVISION NUMBER: 8 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 'AID CLAIMS. INSR TYPEOFINSURANCE_...................._..l•°PbUCYEFF POLIC'YEXP............ LTR ��f POLICY NUMBER fMMIDDrYYYY) I'MWODNYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY 16602NO38269TIL19 04/01/2019 04/0112020 EACH OCCURRENCE Is 1,000,000 `T9WWWTO RENTED ......-� CLAIMS -MADE 1E OCCUR _i,9fiEm@u(AS,;LLm� wrtrwwemca $..._ 1,000,000 GEN'tAGGR'EG'A'T'E LIMITAPPLIES PER: .e•...._� POLICY 0, PECOT- LOC OTHER, AUTOMOBILE LIABILITY ANY AUTO OWNED AUTOS ONLY HIRED AUTOS ONLY UMBRELLA LIAR SCHEDULED AUTOS NON -OWNED AUTOS ONLY OCCUR EXCESS LIAR V u CLAIMS -MADE DEI D I RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y 1 N ANYPROPR IETORIPARTN ERIEXEC UT I VE OFFICER/MEMBE R EXCLUDED? NIH (Mandatory in NH) I E.L. DISEASE - EA EMPLOYEEI, $ If yes, describe under q DESCRIPTION OF OPERATIONS below I E.L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule. maybe attached if mora space is required) Re: EI Segundo Masonic Center Association: Twisted Tales event, October 3 - 31, 2019. EI Segundo Teen Center, 405 E. Grand Avenue, EI Segundo. MED EXP (Any one person) $ 5'000 PERSONAL& ADV INJURY $ 1,000,000 ........... GENERAL AGGREGATE $ 2,000,000 _..... ,.LO YCTS-COMP/OPAGG S 2,000,000 The City of EI Segundo, The EI Segundo Rotary, and each party's parent, owners, partners, subsidiaries, affiliates, agents, successors and assigns as now exist or are hereafter constituted, and all of their employees directors, officers, shareholders, members, managers and representatives are included as additional insured where required by written contract. This insurance is primary and non-contribulory over any existing insurance and limited to liability arising out of the operations of the named insured subject to policy terms and conditions. CERTIFICATE HOLDER City of EI Segundo Attn: City Clerk 350 Main Street EI Segundo, CA 90245 ACORD 25 (2016/03) 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. AUTHORIZED REPRESENTATIVE of Marah Risk & Insurance Services Mary Lou Cutaiaf�—o�n�- fN 1988-2016 ACORD CORPORATION, All rights reserved. The ACORD name and logo are registered marks of ACORD COMBINED'SING�tF L�IrdIL $' Ea accGdanll BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ pRO�ERiYOAMAGE $ ..,.,, .., ..,. $ EACH OCCURRENCE $ AGGREGATE $ I STAR,TLITE ERS E.L. EACH ACCIDENT s The City of EI Segundo, The EI Segundo Rotary, and each party's parent, owners, partners, subsidiaries, affiliates, agents, successors and assigns as now exist or are hereafter constituted, and all of their employees directors, officers, shareholders, members, managers and representatives are included as additional insured where required by written contract. This insurance is primary and non-contribulory over any existing insurance and limited to liability arising out of the operations of the named insured subject to policy terms and conditions. CERTIFICATE HOLDER City of EI Segundo Attn: City Clerk 350 Main Street EI Segundo, CA 90245 ACORD 25 (2016/03) 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. AUTHORIZED REPRESENTATIVE of Marah Risk & Insurance Services Mary Lou Cutaiaf�—o�n�- fN 1988-2016 ACORD CORPORATION, All rights reserved. The ACORD name and logo are registered marks of ACORD A AGENCY MARSH RISK & INSURANCE SERVICES POLICY NUMBER CARRIER AGENCY CUSTOMER ID: CNIO1346861 LOC #: San Francisco ADDITIONAL REMARKS SCHEDULE Page 2 of 2 NAMED INSURED THE MOST WORSHIPFUL GRAND LODGE OF FREE AND ACCEPTED MASONS OF THE STATE OF CALIFORNIA ATTN: KHALIL SWEIDY I 111 CALIFORNIA STREET SAN FRANCISCO, CA 94108 NAIL CODE (I, I EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ?5 FORM TITLE: Certificate of Liabillty Insurance I I Waiver of subrogation is applicable where required by wdttBn contract and subject to policy terms and conditions ACORD 101 (2008101) © 2008 ACORO CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED - PERSONS OR ORGANISATIONS FOR BODILY INJURY OR PROPERTY DAMAGE AS REQUIRED BY WRITTEN CONTRACT OR AGREEMENT ENT This endorsement modifies insurance provided under the follaMng: COMMERCIAL GENERAL LIABILITY COVERAGE PART The following is added to SECTION II — WHO IS AN INSURED: Any person or organization that is not otherwise an insured under this Coverage Part and that you have agreed in a written contract or agreement to Include as an additional Insured on this Coverage Part is an Insured, but only: a. With respect to liability for "bodily injury' or "property damage" that occurs subsequent to the signing of that contract or agreement; and b. If the "bodily injury" or "property damage" is caused, in whole or in part; by your acts or omissions in the performance of "your wank" to which that contract or agreement applies or the ads or omissions of any person or organization performing operations on your behalf. The Insurance provided to such additional insured is subject to the following provisions: a. The limits of insurance provided to such additional insured will be the minimum limits that you agreed to provide in the written contract or d, agreement, or the limits shown In the Declarations, whichever are less. b. This insurance does not apply to any person or organization for whom you have purchased an Owners and Contractors Protective policy. c. The insurance provided to such additional insured does not apply to: (1) Any "bodily injury" or "property damage" arising out of the providing, or failure to provide, any professional architectural, engineering or surveying services, Including: (a) The preparing, approving, or falling to prepare or approve maps, shop drawings, opinions, reports, surveys, field orders or change orders, or the preparing, approving, or failing to prepare or approve, drawings and specifications; and (b) Supervisory, inspection, architectural or engineering activities. (2) Any "bodily Injury' or "property damage" caused by "your work" and included in the "products -completed operations hazard" unless the written contract or agreement specifically requires you to provide such coverage for that additional insured during the policy period. If the written contract or agreement does not require that the insurance provided under this Coverage Part apply on a primary basis, or a primary and non-contributory basis, then this Insurance is excess over any valid and collectible other insurance, whether primary, excess, contingent or on any other basis, that is available to the additional insured for a loss we cover, CG D1 "0215 0 2017 The Travelers Indemnity Company. All rights reserved. Page 1 of 1 Includes copyrighted material from Insurance Services Office, Inc. with its permission. COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. XTENC ENDORSEMENT FOR SERVICE INDUSTRIES This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART GENERAL DESCRIPTION OF COVERAGE — This endorsement broadens coverage. However, coverage for any Injury, damage or medical expenses described in any of the provisions of this endorsement may be excluded or limited by another endorsement to this Coverage Part, and these coverage broadening provisions do not apply to the extent that coverage is excluded or limited by such an endorsement_ Tile following listing is a general coverage description only. Read all the provisions of this endorsement and the rest of your policy carefully to determine rights, duties, and what is and is not covered. A. Who Is An Insured — Unnamed Subsidiaries B. Who Is An insured — Employees And Volunteer Workers — Bodily Injury To Co -Employees And Co -Volunteer Workers C. Who Is An Insured — Newly Acquired Or Formed Limited Liability Companies D. Blanket Additional Insured — Broad Form Vendors E. Blanket Additional Insured — Controlling Interest F. Blanket Additional Insured — Mortgagees, Assignees, Successors Or Receivers PROVISIONS A. WHO IS AN INSURED — UNNAMED SUBSIDIARIES The following is added to SECTION II — WHO IS AN INSURED: Any of your subsidiaries, other than a partnership or joint venture, that is not shown as a Named Insured in the Declarations Is a Named Insured if: a. You are the sole owner of, or maintain an ownership interest of more than 50% in, such subsidiary on the first day of the policy period; and b. Such subsidiary is not an insured under similar other insurance. G. Blanket Additional Insured — Governmental Entities — Permits Or Authorizations Relating To Premises H. Blanket Additional Insured — Governmental Entities — Permits Or Authorizations Relating To Operations I. Blanket Additional Insured — Grantors Of Franchises J. Incidental Medical Malpractice K. Blanket Waiver Of Subrogation b. After the date, if any, during the policy period that you no longer maintain an ownership interest of more than 50% in such subsidiary. For purposes of Paragraph 1. of Section II — Who Is An Insured, each such subsidiary will be deemed to be designated in the Declarations as: a. A limited liability company; b. An organization other than a partnership, joint venture or limited liability company; or c. A trust; as indicated in its name or the docurrtents that govem its structure. B. WHO IS AN INSURED — EMPLOYEES AND VOLUNTEER WORKERS — BODILY INJURY TO CO -EMPLOYEES AND CO VOLUNTEER WORKERS No such subsidiary is an insured for "bodily The following is added to Paragraph 2.a.(1) of SECTION II — WHO IS AN INSURED: injury' or "property damage" that occurred, or "personal and advertising injury" caused by an Paragraphs (1)(a), (b) and (c) above do not offense committed: apply to "bodily injury" to a co -"employee" while a. Before you maintained an ownership interest in the course of the co -"employee's" employment of more than 50% in such subsidiary; or by you or performing duties "related to the conduct of your business, or to bodily injuryto CG D4 67 0219 ® 2017 The Travelers Indemnity Company. All rights reserved. Page 1 of 5 Includes copyrighted material of Insurance Services Office, Inc. with its permission. COMMERCIAL GENERAL LIABILITY your other "volunteer workers" wtile performing duties related to the conduct of your business. C. WHO IS AN INSURED - NEWLY ACQUIRED OR FORMED LIMITED LIABILITY COMPANIES The following replaces Paragraph 3. of SECTION II - WHO IS AN INSURED: 3. Any organization you newly acquire or form, other than a partnership or joint venture, and of which you are the sole owner or in which you maintain an ownership interest of more than 50%, will qualify as a Named Insured if there is no other similar insurance available to that organization_ However a. Coverage under this provision is afforded only: (1) Until the 180th day after you acquire or form the organization or the end of the policy period, whichever is earlier, if you do not report such organization in writing to us within 180 days after you acquire or form it; or (2) Until the end of the policy period, when that date is later than 180 days after you acquire or form such organization, if you report such organization in writing to us within 180 days after you acquire or form it; b. Coverage A does not apply to "bodily injury" or "property damage" that occurred before you acquired or formed the organization; and c. Coverage B does not apply to "personal and advertising injury" arising out of an offense committed before you acquired or formed the organization. For the purposes of Paragraph 1. of Section II - Who Is An Insured, each such organization will be deemed to be designated in the Declarations as: a. A limited liability company; b. An organization, other than a partnership, joint venture or limited liability company; or C. A trust; as indicated in its name or the documents that govern its structure, D. BLANKET ADDITIONAL INSURED - BROAD FORM VENDORS The following is added to SECTION II - WHO IS AN INSURED: Any person or organization that is a vendor and that you have agreed in a written contract or agreernerlt to include as an additional insured on this Coverage Part is an insured, but only with respect to liability for "bodily injury" or "property damage" that: a. Occurs subsequent to the signing of that contract or agreement; and b. Arises out of "your products" that are distributed or sold in the regular course of such vendor's business. The insurance provided to such vendor is subject to the following provisions: a. The limits of insurance provided to such vendor will be the minimum limits that you agreed to provide in the written contract or agreement, or the limits shown in the Declarations, whicheverare less. b. The insurance provided to such vendor does not apply to: (1) Any express warranty not authorized by you or any distribution or sale for a purpose not authorized by you; (2) Any change in "your products" made by such vendor; (3) Repackaging, unless unpacked solely for the purpose of inspection, demonstration, testing, or the substitution of parts under instructions from the manufacturer, and then repackaged in the original container; (4) Any failure to make such inspections, adjustments, tests or servicing as vendors agree to perform or normally undertake to perform in the regular course of business, in connection with the distribution or sale of "your products"; (5) Demonstration, installation, servicing or repair operations, except such operations performed at such vendor's premises in connection with the sale of "your products"; or Page 2 of 5 0 2017 The Travelers Indemnity Company. All rights reserved. CG D4 67 02 18 Includes copyrighted material of insurance Services office. Inc. with its permission (6) 'Your products" that, after distribution or sale by you, have been labeled or relabeled or used as a container, part or ingredient of any other thing or substance by or on behalf of such vendor. Coverage under this provision does not apply to: a. Any person or organization from whom you have acquired "your products", or any ingredient, part or container entering into, accompanying or containing such products; or b. Any vendor for which coverage as an additional insured specifically is scheduled by endorsement. E. BLANKET ADDITIONAL INSURED — CONTROLLING INTEREST 1. The following is added to SECTION II — WHO IS AN INSURED: Any person or organization that has financial control of you is an insured with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" that arises out of: a. Such financial control; or b. Such person's or organization's ownership, maintenance or use of premises leased to or occupied by you. The insurance provided to such person or organization does not apply to structural alterations, new construction or demolition operations performed by or on behalf of such person or organization. 2. The following is added to Paragraph 4. of SECTION II — WHO IS AN INSURED: This paragraph does not apply to any premises owner, manager or lessor that has financial control of you. F. BLANKET ADDITIONAL INSURED — MORTGAGEES, ASSIGNEES, SUCCESSORS OR RECEIVERS The following is added to SECTION 11— WHO IS AN INSURED: Any person or organization that is a mortgagee, assignee, successor or receiver and that you have agreed in a written contract or agreement to include as an additional insured on this Coverage Part is an insured, but only with respect to its liability as mortgagee, assignee, successor or receiver for "bodily injury", "property damage" or "personal and advertising injury" that: "COMMERCIAL GENERAL LIABILITY a. Is "bodily injury" or "property damage" that occurs, or is "personal and advertising injury" caused by an offense that is committed, subsequent to the signing of that contract or agreement; and b. Arises out of the ownership, maintenance or use of the premises for which that mortgagee, assignee, successor or receiver is required under that contract or agreement to be included as an additional insured on this Coverage Part. The insurance provided to such mortgagee, assignee, successor or receiver is subject to the following provisions: a. The limits of insurance provided to such mortgagee, assignee, successor or receiver will be the minimum limits that you agreed to provide in the written contract or agreement, or the limits shown in the Declarations, whichever are less. b. The insurance provided to such person or organization does not apply to: (1) Any "bodily injury" or "property damage" that occurs, or any "personal and advertising injury" caused by an offense that is committed, after such contract or agreement is no longer in effect; or (2) Any "bodily injury", "property damage" or "personal and advertising injury" arising out of any structural alterations, new construction or demolition operations performed by or on behalf of such mortgagee, assignee, successor or receiver. G. BLANKET ADDITIONAL INSURED — GOVERNMENTAL ENTITIES — PERMITS OR AUTHORIZATIONS RELATING TO PREMISES The following is added to SECTION II — WHO IS AN INSURED: Any governmental entity that has issued a permit or authorization with respect to premises owned or occupied by, or rented or loaned to, you and that you are required by any ordinance, law, building code or written contract or agreement to include as an additional insured on this Coverage Part is an insured, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" arising out of the existence, ownership, use, maintenance, repair, construction, erection or removal of any of the following for which that governmental entity has issued such permit or authorization: advertising signs, awnings, CG D4 67 0219 0 2017 The Travelers Indemnity Company, All rights reserved. Page 3 of 5 Includes copyrighted material of Insurance Services Office, Inc. with its permission COMMERCIAL GENERAL LIABILITY canopies, cellar entrances, coal holes, driveways, manholes, marquees, hoist away openings, sidewalk vaults, elevators, street banners or decorations. H. BLANKET ADDITIONAL INSURED — GOVERNMENTAL ENTITIES — PERMITS OR AUTHORIZATIONS RELATING TO OPERATIONS The following is added to SECTION II — WHO IS AN INSURED: Any governmental entity that has issued a permit or authorization with respect to operations performed by you or on your behalf and that you are required by any ordinance, law, building code or written contract or agreement to include as an additional insured on this Coverage Part is an insured, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" arising out of such operations. The insurance provided to such governmental entity does not apply to: a. Any "bodily Injury", "property damage" or "personal and advertising injury" arising out of operations performed for the governmental entity; or b. Any "bodily injury" or "property damage" included in the "products -completed operations hazard". 1. BLANKET ADDITIONAL INSURED — GRANTORS OF FRANCHISES The following is added to SECTION 11— WHO IS AN INSURED: Any person or organization that grants a franchise to you is an insured, but oriy with respect to liability for 'bodily injury', "property darnage" or "personal and advertising injury" arising out of your operations in the franchise granted by that person or organization. If a written contract or agreement e>asts between you and such additional insured, the limits of insurance provided to such insured will be the minimum limits that you agreed to provide in the written contract or agreement, or the limits shown in the Declarations, whichever are less. J. INCIDENTAL MEDICAL MALPRACTICE medical services", first aid or "Good Samaritan services" to a person, unless you are in the business or occupation of providing professional health care services. 2. The following replaces the last paragraph of Paragraph 2.a.(1) of SECTION it — WHO IS AN INSURED: Unless you are in the business or occupation of providing professional health care services, Paragraphs (1)(a), (b), (c) and (d) above do not apply to "bodily injury' arising out of providing or failing to provide: (a) "Incidental medical services" by any of your "employees" who is a nurse, nurse assistant, emergency medical technician, paramedic, athletic trainer, audiologist, dietician, nutritionist, occupational therapist or occupational therapy assistant, physical therapist or speech-language pathologist; or (b) First aid or "Good Samaritan services" by any of your "employees" or "volunteer workers", other than an employed or volunteer doctor. Any such "employees" or "volunteer workers" providing or failing to provide first aid or "Good Samaritan services" during their work hours for you will be deemed to be acting within the scope of their employment by you or performing duties related to the conduct of your business. 3. The following replaces the last sentence of Paragraph 5. of SECTION III — LIMITS OF INSURANCE: For the purposes of deterrrining the applicable Each Occurrence Unit, all related acts or omissions committed in providing or failing to provide "incidental medical services", first aid or "Good Samaritan services" to any one person will be deemed to be one "occr arena 4. The following exclusion is added to Paragraph 2., Exclusions, of SECTION I — COVERAGES — COVERAGE A — BODILY INJURY AND PROPERTY DAMAGE LIABILITY: Sale Of Pharmaceuticals 1. The following replaces Paragraph b. of the "Bodily injury" or "property damage" arising definition of "occurrence" in the out of the violation of a penal statute or DEFINITIONS Section: ordinance relating to the sale of pharmaceuticals committed by, or with the b. An act or omission committed in knowledge or consent of, the insured, providing or failing to provide "incidental Page 4 of 5 0 2017 The Travelers Indemnity Company. All rights reserved. CG D4 67 02 19 Includes copyrighted material of Insurance Services Office, Inc. with its permission. S. The following is added to the DEFINITIONS Section: "Incidental medical services" means: a. Medical, surgical, dental, laboratory, x- ray or nursing service or treatment, advice or instruction, or the related furnishing of food or beverages; or b. The furnishing or dispensing of drugs or medical, dental, or surgical supplies or appliances. 6. The following is added to Paragraph 4.b., Excess Insurance, of SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS: This Insurance is excess over any valid and collectible other insurance, whether primary, excess, contingent or on any other basis, that is available to any of your 'employees" for "bodily injury" that arises out of providing or failing to provide "'Incidental medical services" to any person to the extent not COMMERCIAL GENERAL LIABILITY subject to Paragraph 2.a.(1) of Section 11 — Who Is An Insured. K. BLANKET WAIVER OF SUBROGATION The following is added to Paragraph 8., Transfer Of Rights Of Recovery Against Others To Us. of SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS: If the insured has agreed in a contract or agreement to waive that insured's right of recovery against any person or organization, we waive our right of recovery against such person or organization, but only for payments we rnake because of. a. "Bodily injury" or "property damage" that occurs; or b. "Personal and advertising injury" caused by an offense that is committed; subsequent to the execution of the contract or agreement. CG D4 67 0219 0 2017 The Travelers Indemnity Company. All rights reserved. Page 5 of 5 Includes copyrighted material of Insurance services Office, Inc. with its permission. 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 far 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 # I certify that, in the performance of the work set forth in the agreement with the City of EI Segundo, I will not mpioy 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 orkers' compensation provisions of Labor Code § 3700 1 must immediately comply with thus Isio the reernent will automatically become void. Signature of Applicant Date 6l2r��o�g Print Name ''' �� ". AIWd f� ; Agreement for: a -�" ;. tom' Dated: Reviewed by: ,,