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PROOF OF INSURANCE (2015) CLOSEDCERTIFICATE OF LIABILITY INSU MICE 8054 1 2/23/2015' THIS CERTIFICATEIS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON T14E 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 HENYEEN THE ISSUING INSURER(S), AUTHOWED REPRESENTATIVE OR PRODUCE, AND THE ERTIFICATF HOLDER. IMPORTANT: V the certificate holder is an ADDITIONAL INSURED, the po1lc" "! must be endorsed, NE SUBROCATIONIS'4IVIAIVEO, subject to the terms and conditions of the policy, certain pollcfe,s may require an O doTSem,,t„ A statement on this cartfficate, does not confer rights to the certificate holder In Ifeu of such endorsementlelL FOX INSURANCE AGENCY /PHS 709712 P: (866) 467 -8730 F: (888) PO 3OX 33015 SAN ANTONIO TX 78265 avdiRm FIRST CHOICE VENDING, LLC 3030 CARMEL ST UNIT A LOS ANGELES CA 90065 -): (866I 467 -8730 443 - 61121,„'; my (888) 443 -6112 INSURER E ; INSURER F: 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 POUCIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TtP.0 'Frv3v vC6 'AID sues roucrar £"�""""""'°""�"'"".""."".'""�" ,v,,, PUZlCY.'YUNJIER A"IW,GJ+IT".dlk:P' ..a,.,�... ,..... nrxrmrvwvvl .W....... _....._ L1JRT^S COMMERCIAL GENERAL;�LmARI)ILITY CLAIMS -MADE II ^+"^ YOCCIUR A I x 1 General Liab G5ENtAGGAEGATE' LIMIT AP pFSPER. POLICY PRO- ECT OTHER: A070I11I6SILE LIABILITY ANY AUTO ALL OWNED f SCHEDULED AUTOS AUTOS HIRED AU 'AUTOS AUTOS UMBRELLA LIAB OCCUR EKCESS LIAB CLAIMS -MADE lds01J4. J9YAJ WRYII "HUPWRIETORMARTNEFIWEMEoU"rrVe YIN 1FRCERMIEMaER EXCLUDED'? ❑ 11YA 7swdef'" Io NHJ If Wn, describe under 52 SBM ZQ9389 109/01/20141 09/01/2015 EACH OCCURRENCE s2,000,000 '''....... PeNa $1,000, 000 'nee EXP(Any oepureen) $10,000 PERSONAL 8 ADY INJURY 2, —0D0 r 0 0 GENERAL AGGREGATE 4,000,000 ,,,,,,,PRODUCTS- COMP,�OPAGG , 000, OOO (Ee elcrsdent) BODLY INJURY (Par perm BODILY INJURY (Per ncddmQ I EACH OCCURRENCE AGGREGATE ilq E.L. EACRACCIDENT E.L DISEASE -EA EWPLCYEE E.L. DISEASE- POLICYLMIT ucr�w.,rsar*a1W'MVF^A:N",LfPA r7RFAl�I'.CiCCA'TN AI:$I VEFIICIES {JV.f,C7'iD 101, AddMlwal,Ror"AASschedule. may bealtechod IFMw*$p*n W "q'ul"41 Those usual, to the Insuredls Operations. CERTIFICATE HOL13ER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED City of E1 Segundo BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVE C INI ACCORD CE H THE f LCY SI S. Recreation and Parks Department, AUTHORaMREPRESETA 401 SHELDON ST EL SEGUNDO, CA 90245' ACORD 25 ZQ14iQ1 R -. R� -LIJ 1*l m% ( ) The AC'O rrue and logo are registered marks of ACORD £'d d6� :£09� £Zqa:j AGENCY CUSTOMER 10: LOCS- ADDITIONAL; REMARKS SCHEDULE Page Of AGENCY NAMP MURED FOX INSURANCE AGENCY/PHS POLICYMMSER FIRST CHOICE VENDING, LLC SEE ACORD 25 3030 CARMEL ST UNIT A CARRIER NAIC C10DE LOS ANGELES CA 90065 SEE ACORD 25 EFFECUVEOAM SEE ACORD 25 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHE65—LiTO ACORD 'FORM FORM NUMBER: ACORD 25 FORMTITLE: CERTIFICATE OF LIABILITY INSURANCE City of El SegundolIts officers, its officials, and employees are named as an Additional Insured per the Business Liability Cove-rage Form SS,0008 attached to this Policy. Coverage is primary and non-co,ntributory per the Business Liability Coverage Form S 5000 attached to this policy. Notice of cancellation will be provided in accordance with Form 1223. W�VV#m The ACORD name and 1090 are registered marks of ACORD t,, d d66 £09 6 S7 , qej Policy Number: BA040000009423 1141k MERCURY Effective Date: 0912012014 I N S U R A N C E G R O U P Renewal Declarations BUSINESS AUTO DECLARATIONS Issued By: California Automobile Insurance Company P.O. Box 10730 Santa Ana, CA 92711 -0730 Bill i ng: (888) 637 -2176 Claims: (800) 503 -3724 Agent: ABERNATHY INS AGCY, INC 133 E DUARTE RD PD BOX 660010 ARCADIA, CA 91066 Agent Number: 042759 Agent Phone: (626) 574 -1000 ITEM ONE 'GENERAL INIF "IRMATiON Named Insured: RICHARD SALAIVIA DBA: FIRST CHOICE VENDING Mailing Address: 3030 Carmel St, Unit A Los Angeles, CA 90065 -1401 Policy Period: From 09/20/2014 to 09/20/2015 at 12;01 AM Standard Time at your mailing address Form of Business: Individual /Sole Proprietorship Total Policy Premium: $1,931.75 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 IL 00 2109 08 - Nuclear Energy Liability Exclusion IL 00 03 09 08 - Calculation of Premium CA 00 0103 10 - Business Auto Coverage Form CA 01 21 02 99 - Limited Mexico Coverage CA 0143 05 07 -California Changes IL 02 70 08 11- California Changes - Cancellation and CA 23 94 03 06 - Silica or Silica Related Dust Exclusion U -245 - Auto Body Repair Consumer Bill of Rights CA 04 25 05 07 - California Individual Named Insured CA 2154 09 09 - California Uninsured Motorists - Bodily CA 2155 06 10 - California Uninsured Motorists - Physical CA 03 05 02 97 - California Changes Waiver of CDW CA 99 23 03 10 - Rental Reimbursement Coverage CA 99 44 12 93 - Loss Payable Clause MCADS030112 -CA Page 1 of 4 09/20/2014 12:01 AM PT i -d rlCC•70 c 1 fi7 JPIAi Policy Number: BA04DO00009423 Effective Date: 0912012014 jilikk IPA E R C U RY. I N S U R A N CE G R O U P r aw 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 Premium Coverages Symbol The Most We Will Pay For Any One Accident Or Loss Liability 7,8,9 $1,000,000 CSL $1,112 Medical Payments — Uninsured Motorists Bodily 7 $1,000,000 CSL $120 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 $83 Or Lightning. See ITEM FOUR For Hired Or Borrowed Autos. Actual yCash Value Or Cost Of Repair, Whichever Is Less, Minus Deductible Shown in ITEM THREE For Each Covered Specified Causes of Loss 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 $323 Auto. See ITEM FOUR For Hired Or Borrowed Autos. See ITEM THREE LIMIT Shown For Each Disablement of An $27 Towing and Labor 7 Auto. Premium For ITEM FOUR (Hired Auto Coverage) $75.00 Premium For ITEM FIVE (Non- Ownership Liability) $152.00 Premium For Endorsements $58A0 Miscellaneous Fees and Expense California Consumer Services and Fraud Program Fees $1.75 y Premium � Total Policy 19 31.75 , MCADS030112 -CA Page 2 of 4 7 'f'i Hr,.r, -70 C-. I 4.7 IPIAI Policy Number_ BA040000009423 Effective Date: 09/20/2014 1111kMERCURY I I S I S U R A N C E G R O U P ITEM THR1eE� • St NEbULE GF COVERED A T S 1 OU OWN Aut...r city ST ZipCode L Vehicle Covered Description VIN Garaging Cost New Auto No. Equip. 1 2013 CHEVROLET 1GB3G26GSD1161835 Arcadia CA 91001 $27,275 $10,000 Covered Radius Usage Special Industry Class Loss Payee Auto No. (In rAlles) 1 0-50 Service4Use Not Otherwise VAULT FOR ALLY FINANCIAL, PO Box 8121 Cockeysville, MD COVERAGES, PREMIUMS, LIMITS, AND DEDUCTIBLES (Absence of a deductible or limit entry in any column below means that the Hmit or deductible entry in the corresponding ITEM TWO column applies instead.) Liability Premium Auto Payments Damage Comprehensive rcal UM Property Covered UM Bodily in}ury Auto No. Premium Premium Premium Deductible Premium 1 51,112 5120 $1,OQ0 $83 Specified Causes Of Loss Collision Towing & Labor Covered CDW Limit Per Auto No. Deductible Premium Deductible Premium Premium Premium Disablement 1 $1,aao $323 511 $100 Sze Covered Rental Reimbursement Auto Loan/Lease Audio, Visual, & Data Equipment Total Vehicle Auto No. Maximum Payment premium Gap Premium Limit Premium Premium Each Covered Auto 1 S50 per dav130 days $47 $1,723 MCADS030112 -CA p•d Page 3 of 4 dGF :70 q L j77 aeN Policy Number: BA040000009423 (effective Date: 09/20/2014 ZBM 4"""Ll AIR k M E R CURY. I NS URA N CE G R D U P . _ TOTAL PR E I1U S -L, Liability $1,112 Medical Payments Uninsured Motorists Bodily Injury $120 uninsured Motorists Property Damage Collision Deductible Waiver $11 ...� Comprehensive $83 Specified Causes of Loss �._.� _. .._ .. _.... ... Collision $ 323 Towing and Labor $27 Rental Reimbursement $47 Loan /Lease Gap $75 Audio, Visual and Data Electronic Equipment I`I"EM FOUR CI1 Ii E O' HIR1511 OR 13O1RR OWED C*V EItE6 AUTO W"W"MKKfIAGE °;AI�91 PRI: III Iily+iSr Cost of hire means the total amount you incur for the hire of "autos" you don't own (not including "autos" you borrow or rent from your partners or "employees" ortheir family members). Cost of hire does not include charges for services performed by motor carriers of property or passengers. Estimated Liability Coverage Physical Damage Coverage Total ITEM Annual Cost Of Hire "'_ Premium Limit Of Insurance Premium FOUR Premium Actual Cash Value Or Cost Of Repair, If Any $75 Whichever Is Less, Minus $500 Deductible $75 For Each Covered Auto. Additional Equipment Cost New Covered Description Cost New Equipment Type Auto No. 1 Straight /Box Truck $10,000 Converted Truck Bed MCADS030112 -CA Page 4 of 4 t,„d dgp:7.o q I, 177 MAI To: City Of El Segundo I am self employed and therefore I do not carry workman's compensation insurance coverage. Sincerely, �........�.. Richard Salem* 6•d de 6:00 9 6 £Z qej