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PROOF OF INSURANCE (2018 - 2018) CLOSED a CERTIFICATE OF LIABILITY INSURANCE DAM 2018 THIS CERTIFICATEIS 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(les)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). _ W PRODUCER CONTACT ................. C' NAME' FOX INSURANCE AGENCY/PHS (A/CNo,6a): (866) 467-8730 �(IdAd No): (888) 443-6112 709712 P: (866) 467-8730 F: (888) 443-6112 ADDRESS: PO BOX 33015 INSURER(S)AFFORDING COVERAGE NAICN SAN ANTONIO TX 78265 INSURERA: Sentinel Ins Co LTD 11000 ...._...__......................... INSURED INSURERS. INSURER C FIRST CHOICE VENDING, LLC INSURER D: 3030 CARMEL ST UNIT A INSURER E: LOS ANGELES CA 90065 INSURER F: I 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 POLICYCH PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT NTH RESPECT TO WHITHI WIWIS 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 OFLNSURANCE PADDL SeUM POLICYNUMRER / IJ YM*V/ POLICYEXP L/M1TS COMMERCIAL GENERAL LIABILITY I EACH OCCURRENCE S2, 000, 000 A CLAIMS-MADE r-1-1 OCCUR I DAMAGERENTED $1 000, 0 0 0 PREMISESS((Ea occurrence) 1 General Liab X X 52 SBA 803195 09/01/2017 09/01/2018 I MED EXP(Any one person) g� 01 000 PERSONAL&ADV INJURY Is 2, 000, 000 l GENT AGGREGNiE LIMIT APPLIES PER: GENERAL AGGREGATE 5 4 1 000, 000 POLICY I I PRO-0 LOC PRODUCTS-COMP/OP AGG I:s 4/ 0 0 0,0 0 0 OTHER:II B b AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) ANY AUTO BODILY INJURY(Per person) OWNED SCHEDULED „ AUTOS ONLY AUTOS BODILY INJURY(Per accident $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident u X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $1, 000, 000 A EXCESS LIAB CLAIMS-MADE 52 SBA R03195 09/01/2017 09/01/2018 AGGREGATE $11 0001 000 DEDI X RETENTION S 10,0 0 0 $ WORKERS COMPENSATION X PER R OTH- ANDEMPLOYERS'LLIRDUTY STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $1, 000, 000 OFFICER/MEMBER EXCLUDED? W ...._...... A ......... A (Mandatory in NH) ❑ 52 WFC I02647 12/18/2017 12/18/2018 ELDISEASE-EA EMPLOYEE sl, 0001 000 If yes,describe under POLICY LIMIT DISEASE11, 000,L E. . - DESCRIPTION OF OPERATIONS below 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 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. The City of El Segundo A�UFH+OR/ZEDREPRESENTATIVE 401 SHELDON ST V udr>zr�o CSL EL SEGUNDO, CA 90245 ©1988-2016 ACORD CORPORATION.All rights reserved, ACORD 26(2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: LOC#: ADDITIONAL REMARKS SCHEDULE Page of AGENCY NAMED INSURED FOX INSURANCE AGENCY/PHS POLICY NUMBER FIRST CHOICE VENDING, LLC SEE ACORD 25 3030 CARMEL ST UNIT A CARRIER NAIC CODE LOS ANGELES CA 90065 SEE ACORD 25 p EFFECTIVEDATE: SEE ACORD 25 J ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM FORMNUMBER: ACORD 25 FORMTITLE: CERTIFICATE OF LIABILITY INSURANCE I The City of E1 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. ACORD 101 (2014/01) C 2014 ACORD CORPORATION,All rights reserved.. The ACORD name and logo are registered marks of ACORD it THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. POLICY CHANGE This endorsement changes the policy effective on the Inception Date of the policy unless another date is indicated below: Policy Number: 52 SBA R03195 DX Named Insured and Mailing Address; 1ST CHOICE VENDING, LLC 3030 CARMEL ST, UNIT A LOS ANGELES CA 90065 Policy Change Effective Date: 04/24/18 Effective hour is the same as stated in the Declarations Page of the Policy. Policy Change Number: 005 Agent Name: FOX INSURANCE AGENCY/PHS Code: 709712 POLICY CHANGES: SENTINEL INSURANCE COMPANY, LIMITED ANY CHANGES IN YOUR PREMIUM WILL BE REFLECTED IN YOUR NEXT BILLING STATEMENT.IF YOU ARE ENROLLED IN REPETITIVE EFT DRAWS FROM YOUR BANK ACCOUNT, CHANGES IN PREMIUM WILL CHANGE FUTURE DRAW AMOUNTS. THIS IS NOT A BILL. ADDITIONAL PREMIUM DUE AT POLICY CHANGE EFFECTIVE DATE: $15.00 RATES AND PREMIUMS ARE CHANGED, FORM NUMBERS OF ENDORSEMENTS REVISED AT ENDORSEMENT ISSUE: IH12001185 WAIVER OF SUBROGATION PRO RATA FACTOR: 0.356 THIS ENDORSEMENT DOES NOT CHANGE THE POLICY EXCEPT AS SHOWN. Form SS 12 11 04 05 T Page ool Process Date: 04/24/18 Policy Effective Date: 09/01/17 Policy Expiration Date: 09/01/18 POLICY NUMBER: 52 SBA R03195 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF SUBROGATION LAKEWOOD CENTER, MACERICH LAKEWOOD LP, MACERICH LAKEWOOD GP LLC, PACIFIC PREMIER RETAIL TRUST LLC, PACIFIC PREMIER RETAIL LLC, MACPT LLC, MACERICH PPR CORP, MACERICH ZETA HOLDINGS LLC, THE MACERICH PARTNERSHIP L.P, THE MACERICH COMPANY, RPMJV LLC, MACERICH MANAGEMENT COMPANY 500 LAKEWOOD CENTER LAKEWOOD, CA 90712 RE: UNIT A � THE CITY OF EL SEGUNDO, ITS OFFICERS, OFFICIALS, EMPLOYEES, AGENTS, AND VOLUNTEERS 401 SHELDON ST EL SEGUNDO, CA 90245 Form IH 12 00 11 85 T SEQ. NO. 003 Printed in U.S.A. Page 001 Process Date: 04/24/18 Expiration Date: 09/01/18 STATE OF CALIFORNIA AUTOMOBILE INSURANCE LIABILITY IDENTIFICATION CARD POLICY NUMBER EFFECTIVE DATE EXPIRATION DATE BA040000009423 09/20/2017 09/20/2018 California Automobile Insurance Company NAIC#38342 This insurance complies with CVC S16056.S16500.5 NAMED INSURED RICHARD SALAMA DBA: FIRST CHOICE VENDING YEAR MAKE MODEL VIN 2013 CHEVROLET EXPRESS CUTAWAY G3500 1GB3G2BG5D1161835 AGENT: ABERNATHY INS.AGCY.,INC# AGENT'S PHONE NUMBER: (800)564-4452 TO REPORT A CLAIM, 24 HOURS A DAY, 7 DAYS A WEEK PLEASE CALL(800) 503-3724 STATE OF CALIFORNIA AUTOMOBILE INSURANCE LIABILITY IDENTIFICATION CARD POLICY NUMBER EFFECTIVE DATE EXPIRATION DATE BA040000009423 09/20/2017 09/20/2018 California Automobile Insurance Company NAIC#38342 This insurance complies with CVC S16056.S16500.5 NAMED INSURED RICHARD SALAMA DBA: FIRST CHOICE VENDING YEAR MAKE MODEL VIN 2015 CHEVROLET EXPRESS CUTAWAY G3500 1GB3G3CG6F1252104 AGENT: ABERNATHY INS.AGCY., INC# AGENT'S PHONE NUMBER: (800)564-4452 TO REPORT A CLAIM, 24 HOURS A DAY, 7 DAYS A WEEK PLEASE CALL(800) 503-3724 THE COVERAGE PROVIDED BY THIS POLICY MEETS THE MINIMUM LIABILITY LIMITS PRESCRIBED BY LAW IF YOU HAVE AN ACCIDENT * Notify the police immediately. * Write down names, addresses,telephone numbers, driver license numbers and license plate numbers of all persons involved and of witnesses. * Please note any damage to other vehicles. * Do not admit fault. Do not discuss the accident with anyone except your agent, Mercury or the police. * Immediately report all claims to Mercury at (800) 503-3724. * Please take photos if possible. ID-CA(0112) THE COVERAGE PROVIDED BY THIS POLICY MEETS THE MINIMUM LIABILITY LIMITS PRESCRIBED BY LAW IF YOU HAVE AN ACCIDENT * Notify the police immediately. * Write down names, addresses,telephone numbers, driver license numbers and license plate numbers of all persons involved and of witnesses. * Please note any damage to other vehicles. * Do not admit fault. Do not discuss the accident with anyone except your agent, Mercury or the police. * Immediately report all claims to Mercury at (800) 503-3724. * Please take photos if possible. ID-CA(0112) 1i 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: 01 Effective Date: 05/11/18 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: 1ST CHOICE VENDING, LLC 3030 CARMEL ST UNIT A 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 Job Description THE CITY OF EL SEGUNDO FILLING VENDING MACHINES 401 SHELDON ST EL SEGUNDO, CA 90245 Countersigned by Authorized Representative Form WC 04 03 06 (1) Printed in U.S.A. Process Date: 05/11/18 Policy Expiration Date: 12/18/18