PROOF OF INSURANCE (2018 - 2019) CLOSED a DATE(MM1DDrYYYY)
ACiORL? CERTIFICATE OF LIABILITY INSURANCE
ice.."•-" 1 091`!112018
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 bolder 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 r'igh'ts to the certificate holder In lieu of such endorserrient s).
PRODUCER ILION
C'ONTACT
Pacific Partners Insurance Agency
WASE Adriana Ramirez
E 949-580-1969 AX25283 Cabot Road Suite 224A �� + N'w,l: 94'9-580-1963
Laguna Hills,CA 92653 lis'S:
License#:OG61086 INsuRER(sa AFFORDING COVERAGE NAIL d
_._..._....INSURER A 2_ 1:1.9�� 4ttit�M9 anC Co 23787
...INSURED r.,.,.....w................_................__._. ... .. .....
INSURER 13
Lisa's Bon Appetit Inc INSURER c......��..... ... _._
DBA Lisa's Bon Appetit
3535 Lomita Blvd INSURERD:
Torrance,CA 90505 INSURERE;
INSURER F:
COVERAGES CERTIFI'C'ATE NUMBER: 00000000-706764 REVISION NUMBER: 123
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.
fNSR' AUDI.tT6H POLICY LFF N POLICY EXP
LTR', TYPE OF INSURANCE WAD IM POLICY NUMBER MMInDfYYYY1 jMMIr)Orr'YYYI LIMITS
A Y'" COMMERCIAL GENERAL LIABILITY Y ACPGL03027769682 0610212018 a 06102/2019 EACH OCCURRENCE $ 2,000,000
CLAIMS-MADE OCCUR VY O 'I�H'EN1EU
�. DX ,.DEI $ 100,000
i MED EXP(Any one person) $ 5,000
PERSONAL&ADV INJURY -._.m$ 2,000,000
GEN"L AG'GREGA'TE LIMIT APPLIES PER: I GENERAL AGGREGATE ,000,000
. C LOG , ., ,l POLICY'��JE0QU0
OTHER: $
A AUTOMOBILE LIABILITY ACPGL03027769682 10610212018 06/6212019 COMBINED SINC'LELIMIT $
1,0 ,__,f
ANYAUTO [BODILY INJURY(Perperson) $ , m_
OWNED SCHEDULED BODILY INJURY(Per¢celdenl) $
1AUTOS ONLY AUTOS
HIRED NON-OWNED i'-PR{T'pERTY'OAMkGE $ ...--....------_....m.m.... .
XAUTOS ONLY X AUTOS ONLY fPr.I'rrxkEolall
. UMBRELLA LIAB CLAIMS-MADE AGGREGA U RENCE................... $
$ .. .��S ...
..... OCCUR EACH._.-,.
EXCESS LIAB . ..._........
DED RETENTION ......
WORKERS COMPENSATION .-d STATUTE I ERPER N
I
AND EMPLOYERS"UA,BILnY
ANY PROPRIETOR/PARTNERIEXECUTIVE YE.L.EACH ACCIDENT S
OFFICERIMEMBER EXCLUDED? NIA!
(Mandatory In NH) E.L.DISEASE-EA EMPLOYE S
_
DE
OF OPERATIONS below .-......._..._........._........................_.....................
Ifyes descrlb¢urdor
E.L.DISEASE POLICY LIMIT I,$
A Liquor Liability ACPGL03027769682 06/0212018 06/0212019 Aggregate $4,000,000
A Liquor Liability ACPGL03027769682 0610212018 0610212019 Each Cause $2,000,000
_I
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,AddlOonal Remarks Schedule,may be attachad If more space Is required)
The City of EI Segundo,Its officers,officials,employees,agents,and volunteers are named as an additional insured with
respects to general liability per CG20100413.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEOF,
The City Of EI Segundo ACCORDANCE WITH THE POLICY PROVI SCE IONISL BE DELIVERED IN
350 Main St
EI Segundo,CA 90245 AUTHDRgeO REPRESE,NTATIVL
I ;w. X04" 4RAM
Q 'Bi.2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD
Printed by RAM on September 11,2018 at 04:49PM
POLICY NUMBER: ACPGL03027769682 COMMERCIAL GENERAL LIABILITY
CG 20 10 04 13
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:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person(s)Or Organization(s)
-- ------ ---- ---------------
The City of EI Segundo, Its officers, officials, employees, agents and volunteers
350 Main St
EI Segundo CA 90245
Location(s)Of Covered Operations
UCLA Health Center., 2275 E Mariposa Ave, El Segundo CA 90245
Information required to complete this Schedule, if not shown above,will be shown in the Declarations.
A. Section II — Who Is An Insured is amended to 2. If coverage provided to the additional insured is
include as an additional insured the person(s) or required by a contract or agreement, the
organization(s) shown in the Schedule, but only insurance afforded to such additional insured
with respect to liability for "bodily injury", "property will not be broader than that which you are
damage" or "personal and advertising injury" required by the contract or agreement to
caused, in whole or in part, by: provide for such additional insured.
1. Your acts or omissions;or B. With respect to the insurance afforded to these
2. The acts or omissions of those acting on your additional insureds, the following additional
behalf; exclusions apply:
in the performance of your ongoing operations for This insurance does not apply to "bodily Injury" or
the additional insured(s) at the location(s) "property damage"occurring after:
designated above. 1. All work, including materials, parts or
However: equipment furnished in connection with such
1. The insurance afforded to such additional work, on the project (other than service,
insured only applies to the extent permitted by maintenance or repairs) to be performed by or
law; and on behalf of the additional insured(s) at the
location of the covered operations has been
completed; or
CG 20 10 04 13 0 Insurance Services Office, Inc.,2012 Page 1 of 2
CG 2010 0413
2. That portion of "your work" out of which the 1. Required by the contract or agreement;or
injury or damage arises has been put to its 2. Available under the applicable Limits of
intended use by any person or organization Insurance shown in the Declarations;
other than another contractor or subcontractor whichever is less.,
engaged in performing operations for a
principal as a part of the same project. This endorsement shall not increase the
C. With respect to the insurance afforded to these applicable Limits of Insurance shown in the
additional insureds, the following is added to Declarations.
Section III—Limits Of Insurance:
If coverage provided to the additional insured is
required by a contract or agreement, the most we
will pay on behalf of the additional insured is the
amount of insurance:
All terms and conditions apply unless modified by this endorsement.
Page 2 of 2 0 Insurance Services Office, Inc., 2012 CG 2010 04 13
COMMERCIAL GENERAL LIABILITY
CG 72 12 12 16
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
COMMERCIAL GENERAL LIABILITY
COVERAGE ENHANCEMENT ENT EN'DOF SEMI NT
INCLUDING MEDICAL PAYMENTS
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SECTION I — COVERAGES, COVERAGE A with permission of the owner. A separate limit of
BODILY INJURY AND PROPERTY DAMAGE insurance applies to this coverage as described
LIABILITY, 2. Exclusions is amended as follows: in Section III- Limits of Insurance.
1. Paragraph (2)(a) of Exclusion g. Aircraft, Auto SECTION I — COVERAGES, SUPPLEMENTARY
Or Watercraft is replaced with: PAYMENTS — COVERAGES A AND B is amended
(a) Less than 51 feet long; and as follows:
2. The following is added to Exclusion j. Damage 1. Paragraph 1. b. is replaced with:
To Property: b. Up to $2,500 for cost of bail bonds required
(a) Paragraphs (3) and (4) does not apply to because of accidents or traffic law violations
"property damage" to borrowed equipment arising out of the use of any vehicle to which
while not in use, while at the insured's the Bodily Injury Liability Coverage applies.
premises or a job site; or We do not have to furnish these bonds.
(b) Paragraph (4) does not apply "property 2. Paragraph 1. d. is replaced with:
damage" to customers goods while on the d. All reasonable expenses incurred by the
insured's premises for the purpose of being insured at our request to assist us in the
worked on or used in a manufacturing investigation or defense of the claim or
process. "suit", including actual loss of earnings up to
Limit of Insurance - The most we will pay for $500 a day because of time off from work.
damages for "property damage" coverage SECTION II—WHO IS AN INSURED is amended as
provided by this coverage in any one follows:
"occurrence" is $10,000. 1. Paragraph 3. a. is replaced with:
Deductible - Our obligation to pay for a covered a. Coverage under this provision is afforded
loss applies only to the amount of loss in excess only until the 180th day after you acquire or
of $500. We will pay the deductible amount to form the organization or the end of the policy
effect settlement of any claim or "suit" and, upon period, whichever is earlier;
notification of this action having been taken, you 2. The following is added:
shall promptly reimburse us for the deductible as
has been paid by us. This insurance is excess 4. Additional Insured — Automatic Status
over any other valid and collectible insurance. When Required In An Agreement With
3. The last paragraph of 2. Exclusions is replaced You
with: Who Is An Insured includes person(s) or
If Damage To Premises Rented To You is not organization(s) described in Paragraphs a.—
otherwise excluded, exclusions c. through n. do i. below with whom you have agreed in
not apply to damage by fire, lightning, explosion, writing in a contract or agreement that such
person or organization be added as an
smoke or sprinkler leakage to premises while
rented to you or temporarily occupied by you additional insured on your policy.
rented to you or temporarily occupied by you a. Co-Owners Of Insured Premises —
with respect to their liability as co-owner
of the premises.
CG 72 12 12 16 Includes copyrighted material of ISO Properties, Inc.,with its Page 1 of 5
permission.
CG 72 12 12 16
However, their status as additional Structural alterations, new construction,
insured under this policy ends when you or demolition operations performed by
cease to co-own such premises with or on behalf of the person or
that person or organization. organization.
b. Controlling Interest—with respect to However, their status as additional
their liability arising out of their financial insured under this policy ends when you
control of you; or premises they own, cease to be a tenant of such premises.
maintain, or control while you lease or f. Mortgagee, Assignee, or Receiver —
occupy these premises. with respect to their liability as
This insurance does not apply to mortgagee, assignee, or receiver and
structural alterations, new construction arising out of the ownership,
and demolition operations performed by maintenance, or use of the premises by
or for that person or organization. you.
However, their status as additional This insurance does not apply to
insured under this policy ends when structural alterations, new constructions,
they cease to have such controlling and demolition operations performed by
interest. or for that person or organization.
c. Grantor of Franchise or License — However, their status as additional
with respect to their liability as grantor of insured under this policy ends when
a franchise or license to you. their status as mortgagee, assignee, or
However, their status as additional receiver ends.
insured under this policy ends: g. Owners or Other Interest from Whom
(1) when their contract or agreement Land has been Leased — with respect
with you granting the franchise or to their liability arising out of the
license ends or expires; or ownership, maintenance, or use of that
(2) when your license is terminated or part of the land leased to you.
revoked prior to expiration of the This insurance does not apply to:
license as stipulated by the contract (1) Any "occurrence" which takes place
or agreement. after you cease to lease the land; or
d. Lessors of Leased Equipment — with (2) Structural alterations, new
respect to their liability for"bodily injury", construction, or demolition
"property damage" or "personal and operations performed by or on
advertising injury" caused in whole or in behalf of the person or organization.
part by your maintenance, operation or However, their status as additional
use of equipment leased to you by such insured under this policy ends when you
person(s) or organization(s). This cease to lease that land.
insurance does not apply to any h. State or Political Subdivisions —
"occurrence" which takes place after the Permits Relating to Premises — with
equipment lease expires. respect to the following hazards for
However, their status as additional which the state or governmental agency
insured under this policy ends when or subdivision or political subdivision
their lease, contract, or agreement with has issued a permit or authorization in
you for such leased equipment ends. connection with premises you own, rent,
e. Managers, or Lessors of Premises — or control and to which this insurance
with respect to liability arising out of the applies:
ownership, maintenance, or use of that (1) The existence, maintenance, repair,
part of the premises leased to you. construction, erection, or removal of
This insurance does not apply to: advertising signs, awnings,
(1) Any "occurrence" which takes place canopies, cellar entrances, coal
after you cease to be a tenant in
that premises.
Page 2 of 5 Includes copyrighted material of ISO Properties, Inc.,with its CG 72 12 12 16
permission.
CG 72 12 12 16
holes, driveways, manholes, manufacturer, and then
marquees, hoist away openings, repackaged in the original
sidewalk vaults, street banners or container;
decorations and similar exposures; (e) Any failure to make such
or inspections, adjustments, tests
(2) The construction, erection, or or servicing as the vendor has
removal of elevators; or agreed to make or normally
(3) The ownership, maintenance or use undertakes to make in the usual
of any elevators covered by this course of business, in
insurance. connection with the distribution
This insurance does not apply to:
or sale of the products;
(1) "Bodily injury" or "property damage" (f) Demonstration, installation,
or "personal or advertising injury" servicing, or repair operations,
arising out of operations performed except such operations
for the state or municipality; or performed at the vendor's
premises in connection with the
(2) "Bodily injury" or "property damage" sale of the product;
included within the "products- (g) Products which, after
completed operations hazard". distribution or sale by you, have
However, such state or political been labeled or relabeled or
subdivision's status as additional used as a container, part or
insured under this policy ends when the ingredient of any other thing or
permit ends. substance by or for the vendor;
i. Vendors — but only with respect to or
"bodily injury" or "property damage" (h) "Bodily injury" or "property
arising out of "your products" which are damage" arising out of the sole
distributed or sold in the regular course negligence of the vendor for its
of the vendor's business, subject to the own acts or omissions or those
following additional exclusions: of its employees or anyone else
(1) The insurance afforded the vendor acting on its behalf. However,
does not apply to: this exclusion does not apply to:
(a) "Bodily injury" or "property (i) The exceptions contained in
damage" for which the vendor is Subparagraphs d. or f.; or
obligated to pay damages by (ii) Such inspections, adjust-
reason of the assumption of ments, tests or servicing as
liability in a contract or the vendor has agreed to
agreement. This exclusion does make or normally
not apply to liability for damages undertakes to make in the
that the vendor would have in usual course of business, in
the absence of the contract or connection with the
agreement; distribution or sale of the
(b) Any express warranty unau- products.
thorized by you; (2)This insurance does not apply to any
(c) Any physical or chemical insured person or organization, from
change in the product made whom you have acquired such
intentionally by the vendor; products, or any ingredient, part or
(d) Repackaging, except when container, entering into, accom-
unpacked solely for the purpose panying or containing such
of inspection, demonstration, products.
testing, or the substitution of
parts under instructions from the
CG 72 12 12 16 Includes copyrighted material of ISO Properties, Inc.,with its Page 3 of 5
permission.
CG 72 12 12 16
With respect to the insurance afforded to This coverage does not apply if Coverage C
such additional insureds a. — d. described - Medical Payments is excluded either by
above the following is added to the Section the provisions of any coverage forms
III—Limits Of Insurance: attached to the policy or by endorsement.
If coverage provided to the additional SECTION IV — COMMERCIAL GENERAL
insured is required by a contract or LIABILITY CONDITIONS
agreement, the most we will pay on behalf of 1. Condition 2. Duties In The Event Of
the additional insured is the amount of Occurrence, Offense, Claim Or Suit is
insurance: amended to include:
1. Required by the contract or agreement; e. Knowledge of an "occurrence", offense,
or claim or "suit" by an agent or employee of
2. Available under the applicable Limits of any insured shall not in itself constitute
Insurance shown in the Declarations; knowledge of the insured unless you, a
whichever is less. partner, if you are a partnership; or an
This endorsement shall not increase the executive officer or insurance manager, if
you are a corporation receives such notice
Declarations.
applicable Limits of Insurance shown in the of an "occurrence", offense, claim or "suit"
Declarations.
from the agent or employee.
However, this insurance afforded to such 2. Paragraph b. Excess Insurance (1) (b) (ii) of
additional insureds a.—i.described above: condition 4. Other Insurance is replaced with:
1. Only applies to the extent permitted by (ii) That is Fire insurance for premises rented to
law; and you or temporarily occupied by you with
2. Will not be broader than that which you permission of the owner;
are required by the contract or 3. Condition 6. Representations is amended to
agreement to provide for such additional include:
insured.
SECTION III— LIMITS OF INSURANCE d. Your failure to disclose all hazards or prior
"occurrences" or offenses existing as of the
1. The following is added to Paragraph 2: inception date of the policy shall not
The General Aggregate Limit applies separately prejudice the coverage afforded by this
to each of your"locations" owned by or rented to policy provided such failure to disclose all
you or temporarily occupied by you with the hazards or prior "occurrences" or offenses is
permission of the owner. not intentional. This provision does not
2. Paragraph 6. is replaced with: affect our right to collect additional premium
6. Subject to 5. above, the Damage To or exercise our right of cancellation or non-
Premises Rented To You Limit is the most renewal.
we will pay under Coverage A for damages 4. Condition 8. Transfer Of Rights Of Recovery
because of "property damage" to any one Against Others To Us is amended to include:
premises, while rented to you, or in the case If required by a written contract executed prior to
of damage by fire, lightning, explosion, loss, we waive any right of subrogation we may
smoke, or sprinkler leakage, while rented to have against the contracting person or
or temporarily occupied by you with organization because of payments we make for
permission of the owner. The limit is injury or damage arising out of your ongoing
increased to$1,000,000. operations or "your work" done under a contract
3. Paragraph 7. is replaced with: with that person or organization and included in
7. Subject to 5. above, the higher of: the"products-completed operations hazard".
a. $10,000; or 5. The following condition is added:
b. The amount shown in the Declarations 10. Liberalization
for Medical Expense Limit is the most If we revise this coverage form to provide
we will pay under Coverage C for all more coverage without additional premium
medical expenses because of "bodily charge, your policy will automatically provide
injury"sustained by one person. the additional coverage as of the day the
revision is effective in your state.
Page 4 of 5 Includes copyrighted material of ISO Properties, Inc.,with its CG 72 12 12 16
permission.
CG 7212 1216
SECTION V—DEFINITIONS or death resulting from any of these at any
1. Definition 3. "Bodily Injury" is replaced with: time.
3. "Bodily injury" means bodily injury, sickness 2. The following definition is added:
or disease sustained by a person, including "Location" means premises involving the same
mental anguish, mental injury, shock, fright or connecting lots, or premises whose
connection is interrupted only by a street,
roadway, waterway, or right-of-way of a railroad.
All terms and conditions apply unless modified by this endorsement.
CG 72 12 12 16 Includes copyrighted material of ISO Properties, Inc.,with its Page 5 of 5
permission.
ACRO CERTIFICATE OF LIABILITY INSURANCE DAT9/20/2018 Y)
09120/2018
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 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).
PRODUCER CONTACT
NAME:
... .................................
PHONE
Automatic Data Processing Insurance Agency,Inc. AIC No.Ex
(l: ( .. 1
1 Adp Boulevard ADURess:
Roseland,NJ 07068 INSURER(S)AFFORDING COVERAGE NAIC#
INSURER A: Technology Insurance Company,Inc. 42376
_........._._. ._- ..... .................................................................................
INSURED INSURER B:
LISA'S BON APPETIT INC .......... ............................................................................................................................................
........ ... ..,............... ,..... .........
3511 PACIFIC COAST HWY STE G I INSURER C
Torrance,CA 90505 I INSURER D: ..................... ........._..........._
I INSURER E
I INSURER F:
COVERAGES CERTIFICATE NUMBER: 986013 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.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.
ti
AutdL uuI POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE U INSI.1�WVD I POLICY NUMBER (MMIDD,PyYYY) (MGYWNk onfyYYYI LIMITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $
'DW1 E AGt..,l ...KEN I tom_._..
CLAIMS-MADE OCCUR PREMISES Ea occurrence $
MED EXP(Any one person) $
........ _ _—......®..._.._._._._.---------------.------�
PERSONAL&ADV INJURY $
_......................... ............................. ....................._..._.
GEN'L AGGREGATE LIMIT APPLIES PER: GEN_ER_AL AGGREGATE $
_.� POLICY jECT LOC PRODUCTS....COMPIOP AGG.. $... ...............................................ww. .. ,...
www .......................
O'IHER'.
AUTOMOBILE LIABILITY i COMSINED SINGLE LIMIT $
(Ea accldentl
ANY AUTO
BODILY INJURY(Per person) $
ALL OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS AUTOS
NON-OWNED PROPERTY DAMAGE
HIRED AUTOS f ow accldono
AUTOS $
L......_....� �..-........�
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DED RETENTION$ $
WORKERS COMPENSATION X I PER STATUTE I I EOTTH
AND EMPLOYERS'LIABILITY
ANY PROPRIETORIPARTNER/EXECUTIVE YIN
E.L.EACH ACCIDENT $ 1,000,000
A OFF[ N N/A Y TWC3661060 10/0412017 10/0412018 1,000,000
(Mandatory In NH)
DESCRIPTIONV
if yes,descdbe under E.OF OPERATIONS below E.L.DISEASE-POLICY LIMIT L.DISEASE-FA EMPLOYEE
$ 1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required)
This certificate of insurance includes a Waiver of Subrogation in favor of the certificate holder.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of EI Segundo ACCORDANCE WITH THE POLICY PROVISIONS.
350 Main Street
EI Segundo,CA 90245 AUTHORIZED REPRESENTATIVE
u
,@ 1988-2014 ACORD CORPORATION.All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06
(Ed.04-84)
WAIVER Of OUR RIGHT To RECOVER FROM OTHERS ENDORSEMENT-CALIFORNIA
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
City of EI Segundo Specific waiver per written contract
EI Segundo , CA 90245
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 9/11/2018 Policy No. ..—T-W,Q3661060i ..,.w Endorsement No. 4
Insured LISAS BON APPETIT,INC. Premium$ 32763
Insurance Company Technology Insurance Company, Inc. e.
fir. p
Countersigned t� �, *.a-.. ^�" ,; ...„
WC 04 03 06
(Ed.04-84)