Tacos de Los Altos-Certificate of Insurance-2014`ski CERTIFICATE OF LIABILITY INSURANCE
DA ai021=14"'
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: Ifthe certificate holder Is an ADDITIONAL INSURED, the policy(les) must be endorsed. It SUBROGATION IS WAIVED, subject to the
terms and conditions of the policy, certain policies my require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endoreemengs).
PRODUCER
NAMEA T MOBandll
PXONE FAY
No:
Mo Sandell
EMAIL
AooaEsa:
2425 Porter Street, STE 18
INSUR $ AFFORDING COVERAGE
NAIC0
Soquel, CA. 95073
INSURER A: Penn -Star Insurance Company
_
INSURED Tacos de Los
INSURER B: Farmers
159 Bridges Court
INSURER C:
Fremont, CA. 94536
INSURER D:
INSURER E:
INSURER F:
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 REOUIREMENT, 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 CI -AIMS.
MISS
TYPE OFIN6UMNCE
A DL
BR
POLICY NUMBER
PpLICY EFF
MMIDDIYYYY
PoLICY E%P
MNNDIWYY
UNITS
.6113.
A
GENERAL UAINUTY
X COMMERCIAL GENERAL INBILMY
CIANS-MADE 91 OCCUR
r
r
CPS5042933
1110I2013
11IOlQO14
EACH OCCURRENCE
$ 1 DOD00D
PREMISES Ee.Tsr.
S100DOO
N ED EXP (Any one Tenon)
$ 5,000
PERSO. a ADV INJURY
$1000000
GENERALAGGREGATE
$ 2,000,000
GENLAGGREGOTE
POLICY
LIMIT APPLIE6 PER:
PR0. La
PRODUCTS-COMP/OPAGG
$2000 O0
S
g
AUTOMOBILE
LIABILITY
A AUTO
ALL OVMEO X SCHEDULEO
areas MOTOO�Po
HIRE)AUTOS AUTOS
r
I
805050224
11/012013
1110112014
Ee .1
S I000000
BODILY INJURY(Per,)
$
BODILY INJURY(P.—ioNnn
S
PROPERTY DAMAGE
P.—ERN
i
i
UMBREUA 13
EXCESS LISE
OCCUR
CLAIMS -MADE
r
EACH OCCURRENCE
$
AGGREGATE
S
DEO j I RETENUO.S
$
VORKEASOOMPEHBATSON
ANDEMPLOYERa'UJUHURYLIMITS
ANY PROPRIETgLPARTNERIEXECUTIVE TIN
OFFICEIMEM DER EXCLUOEDi ❑
I IMam,nonr NN)
N/A
r
WC
TRYSTATU- OTH-
EL EACH ACCIDENT
$
El.DISEASE - EA EMPLOYE
$
EL. DISEASE -POLICY LIMIT
$
rr
DESCRIPTION OP OPERAIVMSI LOEATIONS I VEHICLES (AWeM1 ACORD 1M, Additioml RemaMa Schedule, emom apw Is requ4atl)
Certificate Holder and the City of Cupertino and their officers, employees, representatives and agents are named as additional insured per the attached Additional
Insured endorsement
CERTIFICATE HOLDER CANCELLATION
Additional Insured
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Cupertino City Hall
ACCORDANCE WITH THE POLICY PROVISIONS.
10300 Torre Avenue
AUTHORIZED REPRESENTATIVE
Cupertino, CA. 95014
01883-2M`AMD CORRIDR"ATION. All rights reserved.
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD
COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ CAREFULLY
ADDITIONAL INSURED AUTOMATIC STATUS WHEN REQUIRED BY PERMIT OR WRITTEN
CONTRACTOR AGREEMENT
This encampment modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
A. Section 11 - WHO IS AN INSURED is amended to include as an additional insured any person or organization
on whose premises you are performing operations when you and such person or organzation have agreed in writing in a
contract, agreement, or permit, that such person or organization be added as an additional insured on your policy. Such
person or organization is an additional Insured only wilt respect b liability for "bodily injury', "property damage" or
"personal and advertising injury" caused by your ongoing operations while on the premises of such additional insured
and only to the extent that such 'bodily injury", "property damage" or "personal and advertising injury' is caused, in
whole or in part, by your acts or omissions or the acts of omissions of those performing operations on your behalf,
B. Sud. as an addnonal insured for the person or organization to which th is endorsement applies:
1. Commences during the policy period and after such permit or written contract or agreement has been
executed; and
2. Endswhen
a. Your ongoing operations at the additional insured's premises are completed; or
b. The lease of premises expires; or
c. Your agreement to occupy space provided fo you by written permit or person a otgantration
expires;
c. our policy cancel or expires.
whichever occurs first.
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permission
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