We Sushi-Certificate of Insurance-2012'` C"R"� CERTIFICATE OF LIABILITY INSURANCE
DATE(MMlDDlYYW)
04/02/2012
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 FAX
COASTAL BROKERS INS SERVICES -QUESTIONS CONTACT
A!C No Ext : (AIC, No
RVIS INSURANCE
E-MAIL
ADDRESS:
INSURER(S)AFFORDING COVERAGE
NAIL#
1670 BERRYESSA RD
INSURERA : BURLINGTON INSURANCE CO
SAN JOSE CA 95133
INSURED
RODA API, LLC
INSURER B :
2842 CLEMENT ST
INSURER :
INSURER D :
INSURERE:
SAN FRANCISCO CA 94121
INSURERF: JG
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,
EXCLUSIONSAND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
TYPE OF INSURANCE
INSR
WVD
POLICY NUMBER
POLICY EFF
MMIDDIYYYY
POLICY EXP
MMIDDIYYYY
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE
$ 1,000,000
X COMMERCIAL GENERAL LIABILITY
'"Y ".
DAMAGE TO RENTED
PREMISES Ea occurrence
$ 100,000
CLAIMS-MADE � OCCUR
MED EXP (Any one person)
$ 5,000
A
846B000883
2-10-2012
2-10-2013
PERSONAL&ADV INJURY
$ 1,000,000
GENERAL AGGREGATE
$ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGG
$ 2,000,000
PRJECOT F7 LOC
X POLICY F7
$
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
Ea accident
$
BODILY INJURY (Per person)
$
ANY AUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE
(Per
Per accident
$
NON-ONED
HIRED AUTOS AUTOS
UMBRELLA LIAR
OCCUR
EACH OCCURRENCE
$
AGGREGATE
$
EXCESS LIAR
CLAIMS -MADE
DED RETENTION $
$
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y f N
ANY PRO PRIETORfPARTNERfEXECUTIVE
',
WC STATU- OTH-
TORY LIMITS ER
E.L. EACH ACCIDENT
$
OFFICEfMEMBER EXCLUDED? ❑
N f A
E.L. DISEASE - EA EMPLOYE
$
(Mandatory in I
Ityes, describe NOFOPERATION'; belovv
E.L. DISEASE -POLICY LIMIT
$
DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
10 DAYS NOTICE OF CANCEL FOR NONPAYMENT OF PREMIUM
THE CITY OF CUPERTINO AND THEIR OFFICERS, EMPLOYEES, REPRESENTATIVES, VOLUNTEERS AND AGENTS ARE NAMED AS ADDITIONAL
INSURED
CERTIFICATE HOLDER CANCELLATION
ADDITIONAL INSURED:
CUPERTINO CITY HALL
10300 TORRE AVENUE
CUPERTINO
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
CA 95014
All rights reserved.
ACORD 25 (2010105)
The ACORD name and logo are registered marks of ACORD