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PROOF OF INSURANCE (2020 - 2020) CLOSEDDATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 04/14/2020 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(ies) must be endorsed. If SUBROGATIONIS 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 FOX INSURANCE AGENCY/PHS NAME: 52709712 PHONE (866)467-8730 FAX (888)443-6112 (A/c, No, Ext): (A/c, No): The Hartford Business Service Center 3600 Wiseman Blvd E-MAIL San Antonio, TX 78251 ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC# INSURED I INSURER A: Sentinel Insurance Company Ltd. 11000 VENDING AND AMUSEMENTS INC. Hartford Insurance Company of the 37478 3235 N SAN FERNANDO RD UNIT IF INSURER e . Midwest LOS ANGELES CA 90065-1434 I INSURERC: INSURER D : INSURER E 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.NOTWITHSTAN DING 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR WVD (MM/DD/YYYYI (MM/DD/Y YYYI A COMMERCIAL GENERAL LIABILITY CLAIMS -MADE Fx I OCCUR X General Liability GEN'LAGGREGATE LIMIT APPLIES PER: POLICY ❑PRO LOC JECT OTHER: AUTOMOBILE LIABILITY ANY AUTO $2,000,000 ALL OWNED i SCHEDULED AUTOS AUTOS _ HIRED NON -OWNED AUTOS AUTOS X X X UMBRELLA LIABOCCUR A EXCESS LIAB CLAIM MADE S DEDJ X I RETENTION $ 10,000 WCJRKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY YIN B PROPRIETOR/PARTNER/EXECUTIVE N/A X OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below EACH OCCURRENCE $2,000,000 DAMAGE TO RENTED $1,000,000 PREMISES (Ea occurrence) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED MED EXP (Any one person) $10,000 52 SBA R03195 09/01/2019 09/01/2020 I PERSONAL & ADV INJURY $2,000,000 GENERAL AGGREGATE $4,000,000 PRODUCTS - COMP/OP AGG $4,000,000 COMBINED SINGLE LIMIT (Fa accident) BODILY INJURY (Per person) BODILY INJURY (Per accident) PROPERTY DAMAGE (Per accident) I EACH OCCURRENCE $1,000,000 52 SBA R03195 09/01/2019 09/01/2020 1 AGGREGATE $1,000,000 X (PER STATUTE I IEORH E.L. EACH ACCIDENT $1,000,000 52 WEC 102647 12/18/2019 12/18/2020 I E.L. DISEASE -EA EMPLOYEE $1,000,000 E.L. DISEASE - POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Those usual to the Insured's Operations. Please see Additional Remarks Schedule Acord Form 101 attached. CERTIFICATE HOLDER CANCELLATION City of EI Segundo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 350 MAIN ST BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED EL SEGUNDO CA 90245-3813 IN ACCORDANCE WITH THE POLICY PROVISIONS. REPRESENTATIVE �AUTHORIZED - © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: LOC#: ADDITIONAL REMARKS SCHEDULE AGENCY FOX INSURANCE AGENCY/PHS POLICY NUMBER SEE ACORD 25 CARRIER SEE ACORD 25 NAIC CODE NAMED INSURED VENDING AND AMUSEMENTS INC. 3235 N SAN FERNANDO RD UNIT 1 F LOS ANGELES CA 90065-1434 EFFECTIVE DATE: SEE ACORD 25 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM FORM NUMBER: ACORD 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE Page 2 of 2 RE: Covered CA Operations Performed By Or On Behalf of the Named Insured. The City of EI Segundo, its officers, officials, employees, agents, and volunteers are an Additional Insured per the Business Liability Coverage Form SS0008 attached to this policy. Notice of cancellation will be provided in accordance with Form SS1223 attached to this policy. Waiver of Subrogation applies in favor of the Certificate Holder per the Business Liability Coverage Form SS0008 attached to this policy. Waiver of Subrogation applies in favor of the Certificate Holder per Waiver of our Right to Recover from Others Endorsement WC040306 attached to this policy. ACORD 101 (2014/01) © 2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY NUMBER: 52 SBA R03195 CHANGE NUMBER: 003 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: BUSINESS LIABILITY COVERAGE FORM SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): CITY OF SEGUNDO IT'S OFFICERS, OFFICALS, EMPLOYEES, AGENTS AND VOLUNTEERS Location(s) Of Covered Operations: REACREATION PARK 401 SHELTON ST. EL SEGUNDO CA 90245 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section C. — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. Form SS 41 70 06 11 Process Date: 04/09/20 B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. Page 1 of 1 Policy Expiration Date: 09/01/20 © 2011, The Hartford (Includes copyrighted material of Insurance Services Office, Inc., with its permission) POLICY NUMBER: 52 SBA R03195 CHANGE NUMBER: 003 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: BUSINESS LIABILITY COVERAGE FORM SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): CITY OF SEGUNDO IT'S OFFICERS, OFFICALS, EMPLOYEES, AGENTS AND VOLUNTEERS Location And Description Of Completed Operations: REACREATION PARK 401 SHELTON ST. EL SEGUNDO CA 90245 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section C. — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property damage" caused, in whole or in part, by "your work" at the location designated and described in the schedule of this endorsement performed for that additional insured and included in the "products - completed operations hazard". Form SS 41 71 06 11 Process Date: 04/09/20 Page 1 of 1 Policy Expiration Date: 09/01/20 © 2011, The Hartford (Includes copyrighted material of Insurance Services Office, Inc., with its permission) /MERCURY Policy Number: BA040000009423 INSURANCE Effective Date: 09/20/2019 Renewal Declarations BUSINESS AUTO DECLARATIONS For resolving issues or other information you can contact your agent or Mercury using the below phone numbers: Issued By: California Automobile Insurance Company P.O. Box 10730 Santa Ana, CA 92711-0730 Billing: (888) 637-2176 Claims: (800) 503-3724 Agent: ABERNATHY INS. AGCY., INC# PO BOX 660010 ARCADIA, CA 91066 Agent Number: 042759 Agent Phone: (800) 564-4452 ITEM ONE GENERAL INFORMATION Named Insured: RICHARD SALAMA DBA: FIRST CHOICE VENDING Mailing Address: 3235 San Fernando Road, 1F Los Angeles, CA 90065-1401 Policy Period: From 09/20/2019 to 09/20/2020 at 12:01 AM Standard Time at your mailing address Business Type: Vending Machine Supplier Business Category: Manufacturing Form of Business: Individual/Sole Proprietorship Total Policy Premium: $13,799.80 This policy may be subject to final audit. In return for the payment of the premium, and subject to all the terms of this policy, we agree with you to provide the insurance as stated in this policy. ENDORSEMENTS ATTACHED TO THIS POLICY IL 00 17 1198 - Common Policy Conditions CA 04 25 10 13 - California Individual Named Insured IL 00 2109 08 - Nuclear Energy Liability Exclusion CA 99 28 10 13 - Stated Amount Insurance IL 00 03 09 08 - Calculation of Premium MCANONFAC0516 - Permanently Attached Non -Factory CA 00 0110 13 - Business Auto Coverage Form CA 01 21 10 13 - Limited Mexico Coverage CA 0143 05 17 - California Changes IL 02 70 09 12 - California Changes - Cancellation and CA 23 94 10 13 - Silica or Silica Related Dust Exclusion IL N 119 10 15 - California Auto Body Repair Consumer Bill of CA 04 44 10 13 - Waiver of Subrogation (Specified) CA 20 48 10 13 - Designated Insured MCA650CW1215 - Transportation Network and Livery CA 2154 10 13 - California Uninsured Motorists Coverage - CA 2155 10 13 - California Uninsured Motorists Coverage - CA 03 05 10 13 - California Changes - Waiver of Collision MCA86100617 - Roadside Assistance Coverage CA 99 44 10 13 - Loss Payable Clause MCADS030817-CA Page 1 of 5 09/20/2019 12:01 AM PT Policy Number: BA040000009423 Effective Date: 09/20/2019 MERCURY 10 'A INSURANCE ITEM TWO SCHEDULE OF COVERAGES AND COVERED AUTOS I This policy provides only those coverages where a charge is shown in the premium column below. Each of these coverages will apply only to those "autos" shown as covered "autos". "Autos" are shown as covered "autos" for a particular coverage by the entry of one or more of the symbols from the Covered Autos Section of the Business Auto Coverage Form next to the name of the coverage. Coverage Limit Coverages Premium Symbol The Most We Will Pay For Any One Accident Or Loss Liability 7,8,9 $1,000,000 CSL $9,682 Medical Payments Uninsured Motorists Bodily 7 $1,000,000 CSL $954 Injury Uninsured Motorists Property Damage Actual Cash Value Or Cost Of Repair, Whichever Is Less, Minus Deductible Shown in ITEM THREE For Each Covered Comprehensive 7 Auto, But No Deductible Applies To Loss Caused By Fire $766 Or Lightning. See ITEM FOUR For Hired Or Borrowed Autos. Actual Cash Value Or Cost Of Repair, Whichever Is Less, Specified Causes of Loss Minus Deductible Shown in ITEM THREE For Each Covered Auto For Loss Caused By Mischief Or Vandalism. See ITEM FOUR For Hired Or Borrowed Autos. Actual Cash Value Or Cost Of Repair, Whichever Is Less, Collision 7 Minus Deductible Shown in ITEM THREE For Each Covered $1,810 Auto. See ITEM FOUR For Hired Or Borrowed Autos. Premium For ITEM FOUR (Hired Auto Coverage) $100.00 Premium For ITEM FIVE (Non -Ownership Liability) $174.00 Premium For Endorsements $305.00 Miscellaneous Fees and Expense California Consumer Services and Fraud Program Fees $8.80 Total Policy Premium $13,799.80 MCADS030817-CA Page 2 of 5 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA Policy Number: 52 WEC 102647 Endorsement Number: Effective Date: 12/18/19 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: VENDING AND AMUSEMENTS INC. 3235 N SAN FERNANDO RD UNIT 1 F LOS ANGELES CA 90065 We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 5 % of the California workers' compensation premium otherwise due on such remuneration. SCHEDULE Person or Organization THE CITY OF EL SEGUNDO 401 SHELDON ST EL SEGUNDO, CA 90245 Countersigned by Form WC 04 03 06 (1) Printed in U.S.A. Process Date: 11/07/19 Job Description 003 Authorized Representative Policy Expiration Date: 12/18/20