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PROOF OF INSURANCE (2018 - 2019) CLOSED CERTIFICATE OF LIABILITY INSURANCE 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(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�I htto the certificate holder In.....l..i..e, u...of.. such^erIandr"'do4`rr senent(s,)° prWDU .......... ..... .......�........ ............�..... FOX riiJV: Nl ' ttJ V .1, -H.S ....:.......... 1 .............. ._._ 709712 .P: (860) 467 -87-�a F: (888) 44:3-61.12 PO BOX '33015 "s;1.n'l V,'-,Ar r Or>rriYa'r..c.rr',rr l'ACf ........................................................................... _._...... S.;a.N ANTONIO TX V8265 „ r Irl . . .,..., .......... .. ..��.."... . . _.... ......................._.....,.,.....�.�.�.........� ......... ,..."_".............., INSUREDIY'!'S4J .,.,........... r"b^Vi ___......................................... ..........................�.�., INSURER D ............................. ....................m..........., IiiI;luwr'rF ............................................... ........................ i7,(.i:'; /':.1k:11I I,I'';.,- t1. '''6.!17 4'::'': INSURIFR F ....................... 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 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. ................ .............,....... .....m ......................... IXYR 1IIDL ,S(.'ktkt' POLIC Lh'X" POLICI'EX), Mr7AICw!t't r'4X9Ed R LIMITS ITR COMMERCIALyGENERAL LIA, rn'.eR i wo rn .................,.,.....,.,, 11 CH ......��..• C:;B.A4MF,-6t(IbAf.)L-.......m,�..•ABILITY ,....W......� I-IAMAGF,1:;-1 FI NGrr,u:e1............�nrtj..�Y..�.(.,.,.,.,.0 V 00X 000 OCCUR ralnaGr_ra wr.IVTI_I> 1. )a 0 p 000 n I''I 1"r'' ME I7 EYP an c-, e.mon f.> v L...........m PERSONAL rs ADV INJURY 2® 0 a 0 X 0 0.................. a 00 �....f........h G"CCI!E�C"67"ELIMI f APPLIES PER: eaIAGGREGATE l,mm:../4l n asI:„I(3.i m o PRO LOG PftODLTGCMPYP(tC( 4IFCT " ,.....,....... 0HIPi„I ... AUTOMOBILE LIABILITY C(:wft oc"Id D SINGLE LIMIT ........................... ...................................... 6 ......................... I ANYAUTC:) Y:1C'Y}II INJi_F,6f'"er 4•wr2,r,,,) OWNER SCHEDULED CIHEDULED AU rOS ONLY ,,,,,,,,,, AUTOS BODILY 61'JJUft1'(Pel accic9an!} HIRED NON-OWNEE) rlra()PERFY DAMAGE ALP OS ONLY AUTOS ONLY (I'rzr arcIdent) _...__. .................. .....,..,...,.,.. .� —" _ ��I,., �"':' n' r1,,,, ,,r'; (',' a(rftEc,arF �LXOOarc?00 .rt. UMBRELLA LIAB OCCUR I ACH OGCUPRENGE A EXCESS LIAR CLAIMS MADE }��Pti f���� , ..... ^" 1 X 000, a a a ............................rrrRrrrrs -r,.,���„,,p,;; .1 f,!,I!ii(i �, wr•rrRlr,Lms..........��; .................... ............................... Y �.Y.......... ........��.� ....�...... rvnh ( ltk Lr V: X "r.r,srcll.rlr ;inr'�rrr” FP ANY PFtOPRII-TORtPAR1 NER/I:XECLITIVE YIN E I_EACH ACCIDENF ' L r 000, a00 OFFIC:EPJiwh_MBER EXCLUDED n NIA .. kPan93YrrY rrr NdEMPLOYEE" ' "L 715Ea3 -FA X a a p ,,,,,,,,,,, II yer,,dusunbe under DLSC RIPTION OF OPERAHONS below. .............. r..FISEasi-.....�, 0 Cl 0 v .......,_. L L......................._. .oL6GY Llwlr 1 r 000,,..............................._ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACOR3 101,Additional Additi...................... ............pired.............._____. ..........................�... ditienal Remarks Schedule,maybe attached if mares ace is required) Those usual to the Insured' s Operations. Please see Additional Remarks Schedule Acord Form 101 attached. .1.111,111.1 .... ". .................................... CERTIFICATEHOLDER CANCELLATION ........................mm.. �W.... ..... 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 e C ..LL.y o f E i Segundo eguf fd J AUTHORIZED REPRESENTATIVE 401 `:311ELDON ST EL ,S.EGl. NDO, CA 90241) _ c p 1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: LOC#: ADDITIONAL REMARKS SCHEDULE Page of AGENCY NAMED INSURED Ft,:�X 1NSLIR.rlNCE ./\(_;ENC."Y'/PH. i ....................................,.,.,.,.,.,.,.,.,.,........... ..............,.,.,.. POLICY NUMBER J-1Rf.:T (_°kkt_)I C}°'� `VI ,' NP i i. C',, k,k,C ACORD :'L, .. 0.30 C11.RPiRl, ST t1NI.'.I:' A CARRIER .....................�, ,.NAIC CODE.,.,..........................I LOS C' 9 0 0 6!! T1.CORr) ,_!L) EFFECTIVE DATE: SEE ACORD 25 ADDITIONAL REMARKS. _._. ..........._ THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM FORMNUMBER: ACORD 25 FORMTITLE: CERTIFICATE OF LIABILITY INSURANCE The City of: F ! Segmnlo, Lks officers, o..t..t iLc:"i a l aq emlk;..I.c>yeeso aqenhs, o:>a"J voI I.InLeurs care an A.aklii k: i.i,n a...l.. insured V..or..s rhe R,a.a:'; 'ia.7 k i a➢:.1.i I i f..y Coverage kpolicy. ' ' Cvera;e Form }rm 1030008 atachcd to r. 'is Nc - .co of „ :n( i1La _ on wiIInIbe � 1iIcuk in ac _orcarcraarkForm _13 , 3 1.Mr.::klr.:d to this FN)iicy. 0:o ver ct.i. rppl ies Ln favor of tI:ue Cer..i..:i f icaf..e Holder par r i..he k;Iar.;i.ra.ess h kb i .k..:i..I..y Coverage rage Form SS0008 ak k:.ac.kr€d to this i..s pa'.' I i.c y in favor o F the I. e C o.r t i.F i c a h c� li o l d o r Y�,�, - Waiver o F Ezr a r.. Ra..qhk to Rec°s:}<,er 1:e.:om Others Endorsement WC040 :06 to thi's w .............................................................................. ACORD 101 (2014101) ©2014 ACORD CORPORATION.All rights reserved, The ACORD name and logo are registered marks of ACORD THE HARTFORD Select Customer Insurance Center 3600 WISEMAN BLVD, SAN ANTONIO TX 78251 Policyholder, please call us at: (866) 467-8730 Agent, please call us at: (866) 467-8730 SERVICE.TX@THEHARTFORD.COM INSURANCE ENDORSEMENT ATTACHED *** PLEASE REVIEW THE CHANGE *** Enclosed is an endorsement for your business insurance policy. Please review it at your convenience. If you have questions or need to make further changes: Policyholder, please call us at: (866) 467-8730 Agent, please call us at: (866) 467-8730 between 7 A.M. and 7 P.M. CST . The premium billing will be mailed to you separately. You can expect to receive it soon. Thank you for allowing us to service your business needs. FOX INSURANCE AGENCY/PHS THE HARTFORD SELECT CUSTOMER INSURANCE CENTER The Hartford Hartford Fire Insurance Company and its Affiliates One Hartford Plaza,Hartford,Connecticut 06155 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: 09/01/18 Effective hour is the same as stated in the Declarations Page of the Policy. Policy Chane umber: 005 Agent e: FOX INSURANCE AGENCY/PHS Code: 709712 LI . 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; $42 .00 LOCATION 001 BUILDING 001 IS REVISED PRO RATA FACTOR: 1.000 THIS ENDORSEMENT DOES NOT CHANGE THE POLICY EXCEPT AS SHOWN. Form SS 12 11 04 05 T Page 001 (CONTINUED ON NEXT PAGE) Process Date: 09/26/18 Policy Effective Date: 09/01/18 Policy Expiration Date: 09/01/19 POLICY CHANGE (Continued) Policy Number: 52 SBA R03195 Policy Change (dumber: 005 BUSINESS LIABILITY OPTIONAL COVERAGES ARE REVISED WAIVER OF SUBROGATION IS ADDED: FORM SS 12 15 LOCATION 001 BUILDING 001 SEE FORM IH 12 00 FORM NUMBERS OF ENDORSEMENTS REVISED AT ENDORSEMENT ISSUE: IH12001185 ADDITIONAL INSURED - PERSON-ORGANIZATION FORM NUMBERS OF ENDORSEMENTS ADDED AT ENDORSEMENT ISSUE: SS 12 15 03 00 IH1200118S WAIVER OF SUBROGATION Form SS 12 11 04 05 T Page 002 Process Date: 09/26/18 Policy Effective Date: 09/01/18 Policy Expiration Date: 09/01/19 POLICY NUMBER: 52 SBA R03195 VfA4 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - PERSON-ORGANIZATION VENDING SOLUTIONS, 5415 CALIFORNIA AVE. SW, SEATTLE, WA. 98136 AZTECA INTERNATIONAL CORP 1139 GRAND CENTRAL AVE GLENDALE, CA 91201 CB RICHARD ELLIS, INC. 3415 S SEPULVEDA BLVD STE 640 LOS ANGELES, CA 90034 LEGACY PARTNERS II GLENDALE N BRAND, LLC LEGACY COMERCIAL PARTNERS LP. ; 101 N. BRAND BOULEVARD STE 1230 GLENDALE, CA, 91203 DOUGLAS EMMETT 1998, LLC, DOUGLAS EMMETT MANAGEMENT, LLC, DOUGLAS EMMETT MANAGEMENT, INC. , DOUGLAS EMMETT, INC, DOUGLAS EMMETT PROPERTIES, LP. 100 WILSHIRE BLVD STE 290 SANTA MONICA, CA 90401 PR GLENDALE PLAZA OFFICE CA, LLC 655 N CENTRAL AVE STE 100 GLENDALE, CA 91203 PRISA LHC, LLC, A DELAWARE LLC, (2) PR GLENDALE PLAZA OFFICE CA, LLC, (3) MCCARTHY COOK & CO, ANY SUCCESSOR IN INTEREST THERETO (EACH OF THE FOREGOING, "LANDLORD") , ANY MORTGAGE LENDER OR GROUND LESSOR OR LANDLORD, ANY MANAGING AGENT OF LANDLORD, AND (DIRECT OR INDIRECT) OWNER OF ANY OF THE FOREGOING, AND ANY BENEFICIARY, OFFICER, DIRECTOR, EMPLOYEE OR AGENT OF ANY OF THE FOREGOING CITY OF POMONA INCLUDING ELECTED OR APPOINTED OFFICIALS, DIRECTORS, OFFICERS, AGENTS, EMPLOYEES, VOLUNTEERS, OR CONTRACTORS. 505 S. GAREY AVENUE PO BOX 660 Form IH 12 00 11 85 T SEQ. NO. 001 Printed in U.S.A. Page 001 (CONTINUED ON NEXT PAGE) Process Date: 09/26/18 Expiration Date: 09/01/19 POLICY NUMBER: 52 SBA R03195 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED ® PERSON-ORGANIZATION POMONA, CA 91769 QUIRE PROPERTIES-777 TOWER LLC 777 S. FIGUEROA STREET-SUITE 375 LOS ANGELES, CA 90017 BROOKFIELD DILA HOLDINGS LLC, BROOKFIELD PROPERTIES MANAGEMENT(CA) , INC. , MAGUIRE PROPERTIES-777 TOWER LLC CITY OF PASADENA, ITS COUNCIL MEMBERS, COMMISSIONERS, OFFICERS, EMPLOYEES AND AGENTS 100 N GARFIELD AVE PASADENA, CA 91101 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. 001 Printed in U.S.A. Page 002 (CONTINUED ON NEXT PAGE) Process Date: 09/26/18 Expiration Date: 09/01/19 POLICY NUMBER: 52 SEA R03195 lot THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF SUBROGATION THE CITY OF' EL SEG DO, ITS OFFICERS, OFFICIALS, EMPLOYEES, AGENTS, AND VOLUNTEERS 401 SHELDON ST EL SEG DO, CA 90245 Form IH 12 00 11 85 T SEQ. NO. 003 Printed in U.S.A. Page 001 (CONTINUED ON NEXT PAGE) Process Date: 09/26/18 Expiration Date: 09/01/19 Policy Number: BA040000009423 doAd INSURANCE Effective Date: 09/20/2018 Renewal Declarations BUSINESS AUTO DECLARATION'S For resolving issues or other information you can contact your agent or Mercury using the below phone numbers: ... .......... ........ . .... Issued By: Agent: California Automobile Insurance Company ABERNATHY INS.AGCY., INC# P.O. Box 10730 PO BOX 660010 Santa Ana, CA 92711-0730 ARCADIA, CA 91066 Billing: (888)637-2176 Agent Number:042759 Claims: (800)503-3724 Agent Phone: (800)564-4452 I ITEM ONE GENERAL INFORMATION Named Insured: RICHARD SALAMA DBA: FIRST CHOICE VENDING Mailing Address: 3030 Carmel St, Unit A Los Angeles,CA 90065-1401 Policy Period: From 09/20/2018 to 09/20/2019 at 12:01 AM Standard Time at your mailing address Business Type: Vending Machine Supplier Business Category: Manufacturing Form of Business: Individual/Sole Proprietorship Total Policy Premium: $10,866.04 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 ....-..mm.._ ...................................................................................................................................-. IL 00 17 1198-Common Policy Conditions CA 04 25 10 13-California Individual Named Insured IL 00 2109 08- Nuclear Energy Liability Exclusion MCANONFAC0516-Permanently Attached Non-Factory IL 00 03 09 08-Calculation of Premium CA 2154 10 13-California Uninsured Motorists Coverage- CA 00 0110 13-Business Auto Coverage Form CA 2155 10 13-California Uninsured Motorists Coverage- CA 01 21 10 13-Limited Mexico Coverage CA 03 05 10 13-California Changes-Waiver of Collision CA 0143 05 17-California Changes MCA86100617- Roadside Assistance Coverage IL 02 70 09 12-California Changes-Cancellation and CA 99 44 10 13-Loss Payable Clause CA 23 94 10 13-Silica or Silica Related Dust Exclusion IL N 119 10 15-California Auto Body Repair Consumer Bill of CA 04 44 10 13-Waiver of Subrogation(Specified) CA 20 48 10 13- Designated Insured MCA650CW 1215-'Transportation Network and Livery MCADS030817-CA Page 1 of 5 09/20/2018 12:01 AM PT Ail Policy Number: BA040000009423N S U R/4 N C E Jo" MERCURY Effective Date: 09/20/2018 ..___............ _.........-...... _._ _..._........m ITEM TWO SCHEDULE OF COVERAGES AND COVERED AUTOS mm ^IT^IT 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. .....................overage Limit Coverages Premium Symbol The Most We Will Pay For Any One Accident Or Loss Liability 7,8,9 $1,000,000 CSL $7,300 _...................................................... ........................... ,.. Medical Payments Uninsured Motorists Bodily 7 $1,000,000 CSL $776 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 $577 Or Lightning.See ITEM FOUR For Hired Or Borrowed Autos. .....••Actual Cash Value Or Cost Of Repair, Whichever Is Less, Specified Causes of Loss Minus Deductible Shown in ITEM THREE For Each Covered Auto For Loss Caused By Mischief Or Vandalism.See ITEM FOUR For Hired Or Borrowed Autos. Actua.lCash.. . .............Or Cost Of Repair,Whichever Is .........-......................__................ Value p Less, Collision 7 Minus Deductible Shown in ITEM THREE For Each Covered $1,733 Auto.See ITEM FOUR For Hired Or Borrowed Autos. ......... ................_..........�..m ................................. ............. ... Premium For ITEM FOUR(Hired Auto Coverage) $100.00 .............................................................................. ......................,,,,... .'..... ( .................................-............ Premium For ITEM FIVE Non-OwnershipLiability) $174.00 ............................................. _._ ....................... Premium For..En..........__._... .Y�......................... Endorsements $199.00 :.............. ................................... Miscellaneous Fees and Expense .....................................m ............................., g ............................ California Consumer Services and Fraud Program Fees $7.04 ............................. �.......................,..,..,.,�,,,,, ......... Total Policy Premium $10,866.04 MCADS030817-CA Page 2 of 5 OooeMERCURY Policy Number: BA040000009423INSURANCE Effective Date: 09/20/2018 4,A ...�........................... ............. _ .................. ITEM THREE SCHEDULE OF COVERED AUTOS YOU OWN Covered .__... .... _ _ _.......... ........... ... .... ...... Garaging Zip Code 1 2013 CHEVROLET EXPRESS Medium Trucks 1GB3G2BG5D1161835 Arcadia CA �, 91007 ..... ...... .....2.......... ., 2015 CHEVROLET EXPRESS Medium Trucks 1GB3G3CG6 6F1252104 Arcadia CA 91007 3 2015 CHEVROLET EXPRESS Medium Trucks 1GB6G5CG7 F1133714 Arcadia CA 91007 4..... .. 2016 CHEVROLET EXPRESS Medium Trucks 1GB A........11 91007 B3GSCG3G1333993 Arcadia C _._............. _............................................................. ...................._ ___..... Na........................ Miles) Vehicle Use _...---Bus•nessUse *Stated..A......................................., Non-Factory .............. Cove Autos... . s (In...,..__.............,,.,. I ......... . ... ............................ mount e Radw Loss Payee ................_.................. .... EGw.m............a......'............ u..LY 1 o Up to 100 Miles service VAULT FOR ALL........, ......... — Ce ...................... ALLY BANK 2 Up to 100 Miles Servi._...................... �................................. 3 Up to 100 Miles Service !i......_...... ..... .......... ..m..................... ........... .......................................... �. 4 Up to 100 M.m........ .. .... ....................es.........................m-. Service._................... —.-._..........................a........................... .-..__-I GM FINANCIAL.......... *Stated Amount coverage lists your vehicle's actual cash value,including the actual cash value of any Non-Factory Equipment permanently attached to the vehicle that you disclose to us,and is the most we will pay for a loss.Non-Factory Equipment coverage is subject to a sub-limit shown on the Declarations.Be sure to check the Stated Amount and Non-Factory Equipment sub-limit at every renewal in order to receive the best value from your Mercury Business Auto policy. _.............................. COVERAGES,PREMIUMS,LIMITS,AND DEDUCTIBLES (Absence of a deductible or limit entry in any column below means that the limit or deductible entry in the corresponding ITEM TWO column applies instead.) _ ......................... .......................................... Y Injury AutoMedical UM Bodil In•ur UM PropertyComprehensive Covered Auto No. Liability Premium Payments premium Damage Premium Premium Deductible Premium 8z.5$1 ....................................... .......................... 1 $194.. ...........m...... u, $1,000 $108 2 $1,825 $194 $1,000 $128 _.......... .............................. u 3 $1,825 $194 _. ........................$.1,000 $173_ �4 ........_�......_.�....$1.... Ip ................................._$.194 ..................................................................�.........._$1,000 .................$..,.6.8.,.................— I_. _. ...................._............... 825 ..............._......._...........................m 1......................... ..... ,...5 -.............................................._......... ................._...........m C.DW................1._ Covere Per Auto No. DePremium Deductible Premium Premium pm-,mm Assistance �.. ecified Causes Of Loss Collision Occurrence Deductible Roadside Asa ......................m,..— Premium Z......................... $1,000 $.3.1.8............................... $11 $100.per._.,........,.......................2 ................. $20 $1,000 $387 $11 $100 per $20 $1,000 $.54.5.5........................................m.$11 $100 p.,......................................................,...._.... i. ................_........._. ......�... �per W.. 3 _ $20 .. ...................................-.. 0 $100 per .......... $20 4 $11 ............................... ........ ........ .....,....................................................... .............. ..................... .... ..............................._.......................... .....................................m. Rental Reimbursement Audio,Visual,&Data Equipment Covered ..,.-,,,,,,,,,,,,,,,,,-m, Auto Loan/Lease Total Vehicle Auto No. Maximum Payment Gap Premium Premium Each Covered Auto premium Limit Premium 2,476.00 2 $2,565.00 ....,,,,,..................i. 3 ............... _._. .......,... $2,796.00 ...._ 4 $2,673.00 ........................... .............................-m... .......................... MCADS030817-CA Page 3 of 5 MERCURY Policy Number: BA040000009423 0000 INSURANCE Effective Date: 09/20/2018 ...................wv........................................................................................... -... rrr......rr_. TOTAL PREMIUMS ........................ ....... _... Liability $7,300 ...................... .......................... Medical Payments Unn insured Motoristsdily Injury .�_....._ w�................................�.........................����......����������.........._.......................... Uninsured Motorists Property Damage V .................... CollisionDeductible Waiver _.....w.w_...................................................... ..............................................................................$44.......-..........-..- J ................................................................................ Comprehensive $577 Specified Causes of Loss ........... .......................... ........ ......... Collision $1,733 Roadside Assistance $80 ................................................. Rental Reimbursement Loan/Lease Gap Audio,Visual and Data Electronic Equipment ...... .......................... ................................ ITEM FOUR SCHEDULE OF HIRED OR BORROWED COVERED AUTO COVERAGE AND PREMIUMS ......................... ......................... 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" or their family members). Cost of hire does not include charges for services performed by motor carriers of property or passengers. Liability Coverage Physical Damage Coverage Estimated Total ITEM Annual ....................................................................................................................................... FOUR Cost Of Hire Premium Limit Of Insurance Premium Premium ......... Actual Cash Value Or Cost Of Repair, If Any $100 Whichever Is Less, Minus$500 Deductible $100 For Each Covered Auto. — _... ................................................................................................................ ................................ ._......_...................._._-........_ - -.__ _wW__.w.__......_...m................. ... ITEM FIVE SCHEDULE FOR NON-OWNERSHIP LIABILITY Number Of Employees(Including Volunteers) Total ITEM FIVE Premium ............................................................................................................... -.__. .................. ......................................... 0-10 $174 I __ADDITIONAL INFORMATION .....................................................w___-._................... Discounts ............... *.._....Auto Pay-EFT Discount * Anti-Theft Driver Information Listed Drivers Excluded Drivers .................................................................................... .-.m ...................................................................................... RICHARD SALAMA ..................................................................................................................................................................................................................... ERICK BARRIENTOSmm....... RICARDO VALENCIA Additional Insureds ........................................................................................................................................................... DOUGLAS EMMETT 2014, LLC 15821 Ventura Blvd. Encino, California 91436 CITY OF PASADENA, ITS COUNCIL MEMBERS,COMMISSIONERS, ET AL MCADS030817-CA Page 4 of 5 Policy Number: BA040000009423INSURANCE Effective Date: 09/20/2018 100 N Garfield Ave Pasadena, California 91101-1726 ......a......................................._.............................................................................. Waiver Of Subrogation .. ....-..-. —_................................................................... ........................................................................................................ CITY OF PASADENA, ITS COUNCIL MEMBERS,COMMISSIONERS, ET AL 100 N Garfield Ave Pasadena, California 91101-1726 MCADS030817-CA Page 5 of 5 ,m 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 �i K Countersigned by Authorized Representative Form WC 04 03 06 (1) Printed in U.S.A. Process Date: 05/11/18 Policy Expiration Date: 12/18/19