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PROOF OF INSURANCE (2022 - 2023) CLOSEDCERTIFICATE OF LIABILITY INSURANCE DA7E(MMIDDfYYYY) 08/03/2022 THIS CERTIFICATE IS ISSUED AS A MATTER OFINFORMATION ONLY AND, CONFERS NO RIGHTS UPOIN 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 IINSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. erfificate holder is an ADDITIONAL INSURED, the policy(fes) must be endorsed. If SUBIROGATIONIS 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 endorsomerl PRODUCER CONTACT ABI FOX AGENCY PHONE (866) 467 8730 FAX 52709712 (A/C, No, Fxt): tAICw N The Hartford Business Service Center 3600 Wiseman Blvd E-MAIL San Antonio, TX 78251 ADDRESS: INSURERS) AFFORDING COVERAGE N Al C Y INSURED VENDING AND AMUSEMENTS INC, 3235 N SAN FERNANDO RD UNIT IF LOS ANGELES CA 90065-1434 COVERAGES CERTIFICATE NUMBER: INSURER A: Sentinel Insurance Company Ltd. 11 0IJ0 INSURER 8 INSURER C: INSURER D: INSURER E: INSURER F: THIS ISTOCERTIFY tFIAT THE POLICIES OF' INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICA7ED,NOIWITIASIANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACI OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IIS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, TN-§ TYPE OF INSURANCE Mylic- INSR S UOR VA/D POLICY NUMBER POLICY EFF WMIDDIYYYY POLICY EXP MMLDafy YY LIMITS --7 COMMFRCIALGFNE ALLIABIL17Y EACH I OCCURRENCE $2,000,000 CLAIMS -MADE OCCUR E —MA(�-E757k]EWTEC ITAPREMISES (Ea occurrence) $1,000,000 X General Liability MED EXP (A,,y — p--) $10,000 A X X 52 SBA R03195 09101/2022 09/01/2023 PERSONAL & ADV 11 $2,000,000 GENERAL AGGREGATE $4,000,000 GEN'I- AGGREGATE LIMIT APPLIES PER: ]OlUC111 PRO- E 11 JE,CT I:xl I--. PRODUCTS - COMPIOP AGG $4,,000,000 071AER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT BODILY INJURY (Per pnman) ANY AUTO ALI- OWNED SCHEDULED AUTOS AUTOS SODILY INJURY (Per ic,cident) --PFR—O HIRED NON -OWNED PERTY DAMAGE AUTOS AUTOS (Per accident) UMBRELLA LIAR X OCCUR AQ-1 1��'��RRENCE $3,000,000 EXCESS LIAB CLAIMS_ MADE 62 SBA R03195 09/01/2022 09101/2023 AGGREGATE $3,000,000 DE-FXTRITENTION$ 10,000 . . ...... . ...... WORKERS COMPENSATION �OTH- AND EMPLOYERS' I I L17Y -��TA711T�I�LR ANY YIN PRCPRFTOrJPARTNFR�FXECUrlVF OFFICERwEclpm EXCLUDED'"NIA . . E.L. EACH ACMDEN7 ...... . ... E.L. DISEASE -EA EMPLOYEE (M—d.t-y Irr NH) If yo5 desv ibe under E - DISEASE - POLICY LIMIT ALlow DESCRIPTION OPOPERATIONS! LOCATIONSI VEHICLES (ACORD 101, Addifl—I Ramarks Schedulo, may ba aftachad if morn sp000 is raquimd) Those usual to the Insured's Operations, —HO,L-D"E—R-"--N d9kfiPIC'ATE CANCELLATIO City of F1 Segundo SHOULD ANY OF THE A&O—VEDESC 350 MAIN ST BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED EL SEGUNDO CA 90245-3813 IN ACCORDANCE WITH THE POLICY PROVISIONS, AIJTHOR17ED RrPRESFNTATIVE (D 11988-20115 ACORD CORPORATION. ACCrights-reserved. ACORD 25 (2016/03) Tile ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER 11): LOCN: ADDITIONAL REMARKS SCHEDULE AGENCY, GENCY . . ...... .. ABI FOX AGENCY FOLICY NUMBEP, SEE ACORD 25 CARRIER SEE ACORD25 NAMED INSURED VENDING AND AMUSEMENTS INC. 3235 N SAN FERNANDO RD UNIT IF LOS ANGELES, CA 90065-1434 EFFECflvr= DATE: SEE ACORD 25 THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACCIRD FORM FORM NUMBER: ACORD25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE Page 2_ of 2— Blanket Waiver of Subrogation applies in favor of the Certificate Holder per the Waiver of Our Right to Recover from Others Endorsernent WC040306,8ttached to this- policy,. Notice of Cancellation will be provided in accordance with Forn'i SS1223, attached to this policy. Coverage is primary and noncontributory per the Business Liability Coverage Form SS0008, attached to this policy. Certificate holder is an additional insured per Additional Insured- Owners, Lessees, or Contractors; Scheduled Person or Organization Form SS4170 and Additional Insured: Owners, Lessees or Cont-actors; Completed Operations form SS4.171, attached to this policy. Waiver of Subrogation applies in favor of the Certificate Holder per the Business Liabillty Coverage Form S,S0008, attached to this policy, ACORD '101 (2014101) ®r 2014 ACORD CORPORATION, All rights reserved, The ACORD name and logo are registered marks of AC ORD a-11 Mid -Century Insurance Company (A Stock Company), FARME R� A Part Of The Farmers Insurance Group Of Companies3 INSURANCE Horne Office: 6301 OwenSMOUth Ave,, Woodland Hills, CA 91367 I TY, 47 Fl— lei1!!1i11111 , 1 ; BUSINESS AUTO V01.00 ITEM ONE Named SALAMA, RICHARD Insured FIRST CHOICE VENDING Mailing 3235 N SAN FERNANDO RDUNIT lF Address LOS ANGELES, CA 90065-1434 Policy Number 60678-58-23 M Policy From 08-23-2022 Period To 03-09-2023 12:01 A.M. Standard time at your mailing address shown above. 0 In return for the payment of premium and subject to all the terms of this policy, we agree with you to provide insurance as stated in this policy. We provide insurance only for those Coverages described and for which a specific limit of Insurance is shown. 0 The following premium credits and discounts applied to the premium associated with this coverage part: co Multiple Policy Discount- Homeowners And Personal Auto Insurance Your Agent Jarme Diaz 12087 Lpz Cnyn Rd 108 Sylmar, CA 91342 (818) 722-2237 00, Email: jdiaz3@farrnersagent.com License#: Oh94157 56-6190 1STEDIVON 06-16 C6190101 566190-ED1 Page 1 of 8 °! CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDIYYYY) 05/11 /2021 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. _ p_.. IMPORTANT: If the certificate olic......... holder is an ADDITIONAL INSURED, the olicy(ies) 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(s).mm PRODUCER 1C9MIACT AUTOMATIC DATA PROCESSING INSURANCE AGCY INC 1 ADP BLVD MS 625 ROSELAND, NJ 07068 (877)677-0428 677-0428 INSURER(S) AFFORDING COVERAGE INSURER A: TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA INSURED INSURER B : FIRST CHOICE VENDING & AMUSEME 3235 SAN FERNANDO ST INSURER C : LOS ANGELES, CA 90065 INSURER D t. INSURER E INSURERmFm..X ................. COVERAGES ........ ......... CERTIFICATE NUMBER: 351459140431131 REVISION NUMBER: 677-0430 NAIC # 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 PAID CLAIMS. INSR LTR TYPE OF INSURANCE .�..,,.....------------------- ADD INSO. SUER AMVD,. POLICY NUMBER 6,...,,.....-..,.,(.MM/D,L?/YYYY...m,,.,,LfY1M/DD/YYYY) POLICY EFF POLICY EXP LIMITS EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY AG ... RENTED CLAWS -MADE ❑OCCUR PR MI S(Eagrgrunnce) MED EXP Any one erson , $ PERSONAL. & ADV INJURY $ GENERAL AGGREGATE $ - GEN L AGGREGATE LIMIT APPLIES PER POLICY [::] PRO- F] LOC JECT PRODUCTS -COMPYOP AGG '.$ __.. $ ........ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ ANY AUTO OWNED AUTOS AUTOS ONLY BODILY INJURY (Per accident) $ HIRED .NON -OWNED AUTOS ONLY '.AUTOS ONLY PROPERTY DAMAGE (Per accident) $ $ 'UMBRELLALIAB OCCUR UMBRELLA EACH OCCURRENCE $ EXCESS LIAB CLAIMS MADE • - -- ••-••- �_-----__—_— AGGREGATE $ RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/N .ANY PROPRIETOR/PARTNER/EXECUTIVE r--1 N/A X UB-BP618732-21 04/13/2021 04/13/2022 X sTaruTE °I H E L EACH ACCIDENT _ $ 1 ,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) EL. DISEASE - EA EMPLOYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L.. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) AS RESPECTS TO WORKERS COMPENSATION COVERAGE, WC 99 03 76 (A) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT-CALIFORNIA (BLANKET WAIVER) HAS BEEN ATTACHED TO THE POLICY. CERTIFICATE HOLDER THE CITY OF EL SEDUNDO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 350 MAIN ST THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN EL SEGUNDO, CA 90245 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD �� ^0, WORKERS COMPENSATION AND ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY HARTFORD CT 06183 ENDORSEMENT WC 99 03 76 ( A) - 001 POLICY NUMBER: UB-8P618732-21-42-G WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA (BLANKET WAIVER) 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. The additional premium for this endorsement shall be 2.00 % of the California workers' compensation pre- mium. Person or Organization ANY PERSON OR ORGANIZATION FOR WHICH THE INSURED HAS AGREED BY WRITTEN CONTRACT EXECUTED PRIOR TO LOSS TO FURNISH THIS WAIVER. Schedule Job Description VENDING MACHINE OPERATORS This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Policy No. Endorsement No. Insured Premium Insurance Company Countersigned by DATE OF ISSUE: 03-16-21 ST ASSIGN: Page 1 of 1