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111M CERTIFICATE DOE fNff°N" NNFN"dMfMATIVI.`,LY On N"rlk"'.GAi'WELY AMEND EXTEND OR ARJER nir COVERAGE AFFORDED BY °rHE
POLICIES BELOW, T[.GV«N CERTIFICATE OF tlfdfN,URANCE DOES fWfT"'f (',0lfS"T'NTUTIE, A CONI"'RAc'T IB T"u m'gf:NM THE ISSUING [N^N81JNTU" R(S),
U°THORIZED REPRESENTATIVE OR PdTON"bTNCIN� R, AND THE CERTIFI. TE q,,T'OILDER,,
Ca T'C ) must Garr a�m �rur.Norsed,,..lf N BROG hTIO e
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suaf))eaf to the ternins nod mr o"Yr"NGf[un s of ff c Ihrrrficy, cert.Wn pokles mmy, ruquWe an wexradol°srrorrtaAnt A a„pafmarrnont on, Ws certffleate does not
confer rigtas to the cerfYfNcate hcwkiu Yra [IEaaaa of such ANarlaursome t(s)
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VENDING NG AN[:u rfMLJSE[MI..N tl f I NCI MUIHICA ar e
3235 fN SA N fERNNANTDO IRD UNIT fp.,.
INSURER a .
LOS ANNi,ELII':S CA 910fUQ :5-1434 � .....,,,
INSURER D
INSURER r
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Irw „ar ERAGES
I ISSUED ....�r ...f.._u�� . 54C0 dG W REVISION
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TIlV aaF MAY NwIAd ipl VN NAdUV AFFORDED BY THE p'",INI3LL
lCfNCU. L uSINN„ AND 1DTIONY O SUCH 0I..IE" LIMITS SHOWN aAAY HAVEBEEN dflfED BY PAfl7 CLAIMS,a
TYPE OF ISSUNAOaDL AlaNaluor� NU�ara LIMITS
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SHOULD fNa I&U r�YrG NUU5pr1[a a5NILN SI4NdIUUP
T fNI Srgwi6a rLS THE NANrNN1VCN DAUftlaSNlr5 NU1l"I NrNarYIPaUY
faNNAlhTY OA ACCORDANCE AGRN[OPV�NafiAH6aNaaNk1NNS
E_SGIUD01CA9024;"381N _AIJ7I40R,Q1l D RILTInES SrA'"'VE
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O,R25 (2 &6103) lbe ACORID mum mf and IIIcq') a11O PeOster of rwnrrrks LDf 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
L CERTIFICATE OF LIABILITY INSURANCE I DATE (MM;0 Y.Yi.
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. THII'S CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER„ AND THE CERTIFICATE HOLDER,
-------
IMPORTANT. It the certificate holder is an ADDITIONAL INSURED, the policy(Nes) must have ADDITIONAL INSURED (provisions or he endorsed.
If SUBROGATION IS WAIVED, subject to the tenmsand conditions of (lie Policy, certain Pollcies may require an endorsement, A statement on
thus Certificate does net confer rG tits to the cert,Ificate holder In lieu of such endorsement S
__.._ ._.._...._. Gl7NTACT
k6DUCE:R :...._
AUTOMATIC DATA PROCESSING INSURANCE AGCY INC
-..(aaafwflrr•r Ise ............_,.... L 1,v�, ra�N..._ifwarLar� �.n____.___..
1 ADIP BLVD MS Fat a
E51AIL
ROSELAND, NJ 0'7068
APIDNIE�S m�clalceclR&TY lmrracent �..-
(877) 677-0428
,. INSURER(�V) AFFORDING COVERAGE � hNAIC 0 ....,.
..._.. ..._.... .. .. ....... .____.. _._ .....__ - ..........._� ... m.,.,�
.....
INSURER A TRAVELERS PROPERTY CASUALTY TY COMPANY OF AAMIPRIrA �
.... _.., M, _......,,,
lViFkFO
INSURER B
FIRST CHOICE VENDING A AMUSI`Nvil
...,.....
32:35SAN FERNANDO ST
INSURER c,
LOS Aw.NGELES„ (,f/''A, :100165
INSURER G:
-----
INSURER E :
INSURER F
C�OVERA ES CERTIFICATE NUMBER. 222782259391462 REVISION NUMBER ._
THIS IS TO CER'71IIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NCTVV'IT'I-ISTANDJ NG ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE: ISSUED OR MAY PERTAIN, THE: INSURANCIE, AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT' TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POL.IC.IES. LIMITS 'SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
INSR ADO SUBR
}7FE ....... .. TYPE OF11NSI.11 U11 RAINCIE. ........ .... LNSLM Ma VO ..._POLICY NUMBER,.,...
POLICY EFP POLICY EX.P
IM1AMfLY[idY'.YYVI . jNA!M1YCtL4fYYVYN.. .. .., .. UMITS
�.
OCCURRENCENT
LgyC
COMMERCIAL GENERAL LIABILITY
µ E 0
]CLAIMS -MADE OCdMR
P FM�. - Irmwrcurw. �
MAED EX.P (Any one EE)n $
....
PERSONAL & ADV IN6JUIRY'
GIEMN'L ACP.CRE:GATE LIMIT APPLIES PER:
GENERAL AGGREGATE
P'CLICY JPt E.CT [D L.i71G.
PRODUCTS -COMPMP AGG $
OTHEIZI
TINGLE. LIMIT
CEOM"IB�
$
AUTOMOBILE LfASIL.ITY
rleDtb
B�OMLY INJURY (Per p�Ar,uon)..
'
ANY ALTO
ICWNED SCHEDULED
AUTOS ONLY AUTOS
BODILY INJURY (Per aacudean@)'��.'�
WRED NON -OWNED
AUTOS ONLY AU'TO,5 ONLY
PROPERTY DAMAGE
(Per accident)
$
+Y
UMBRELLA LAB 3cwCUR
EACH OCCURRENCE S
EXCESS LRAS CLAIMS-MADE..�._
AGGREGATE $
DEC7 I FWETENTVON $
-- �
S
` IR14EIRSCOMPENBATION NAUB-&PS1S732-2'3
04/13/2023 0411312024 TATUaE _jL
LFN
AND EMPLOYERS' LABILITY YIN
ANY PRCPRIIETORMARTNFReEXECUTIVF
E.L. EACH ACCIDENT j ,Qd VR ,C6 0
iMantFR EXCLUDED?
dalory In NHI
E.L. LSEASE- EA EMPLOYEE $ i „000'„000
IA�p eJ, describe Under
JI.:WTION OF OP'ERAIIO NS Inctlewa
LEIL. DISEASE POLIICY LIMIT $ 1 ,000,000
DESCRIPTIONOF OPERATIONS I' LOCATIONS I VEIIIICN.SzS (ACORO 101, Additional Rnmmr'ke Schedule, rnap du attached itmore Space Is urognilrod)
.,._.__.._. .. .. .... ....
rT6ITEwDm __.._..-----.-._..... ..NrIN..._.._.......
....._. .... >mn __.._........._.-..
... — _ ...
CITY OF EL SEGUN,DO
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED (BEFORE
350 MAIN S"I
THE EXPIRATION DATE, THEREOF,, NOTICE WILL BE DELIVERED IN
EL SEGUNDO„ CA 9024E
ACCORDANCE W IT'H'ITIIE POLICY PROVISIONS,
_
AU I14OR.I.PCO REP RE 5EIRN IA TIV C
_. _.._._... _.._, I. ._ ........... ....._... ...... .
.. .. . .........,.
1988-2015 ACORID CORPORATION. All rights reserved.
AC:CIRD 25 (201610) The ACCJRD name and logo are r'eglstered marks D1 ACCIR.CI
�� ^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