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Mayo Mustard-Certificate of Insurance-2012ACORD® CERTIFICATE OF LIABILITY INSURANCE I OA TE {MM/DDNYYY) ~ 04/11/2012 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 r ights to the certificate holder in lieu of such endorsement(s). PRODUCER (916) 387-6800 (916) 244-7318 ~~~~~c Ice Insurance Aqencv Ice Insurance Agency r~gNJo,l:xtl: (916) 387-6800 1 r~~ NQJ;J916) 244-7318 813 F Street, 2nd Floor E·MAIL · f l@i · ADDREss: m o 1cems.com INSURER{S) AFFORDING COVERAGE NAIC# Sacramento CA 95814 INsuRER A: Scottsdale Insurance Comoanv INSURED INSURER B: Farmers Insurance Exchancte Roxie Food Truck, LLC INsuRER c: State Comoensation Insurance Fund 132 City Limit Circle INSURERD: Emeryville, CA 94608 INSURERE: INSURERF: 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 . INSR TYPE OF INSURANCE ·~~~~ ~~~ ~~gM%~ 1 1~2)-6%~ LIMITS LTR POLICY NUMBER GENERAL LIABILITY .; EACH OCCURRENCE $1 000 000 1---=- A .f COMMERCIAL GENERAL LIABILITY ~~~~~U?ta~~r?encel $100 000 :=t:J CLAIMS-MADE 0 OCCUR MED EXP (Any one person) $5 000 CPS1433696 08/01/2011 08/01/2012 PERSONAL & ADV INJURY $1 000 000 r-- :---GENERAL AGGREGATE $2 000 000 7l'L AGGREnE LIMIT APn S PER : PRODUCTS -COMP/OP AGG $1 000 000 POLICY j'f8i LOC $ AUTOMOBILE LIABILITY -&~~~~~~tlSINGLE LIMIT $1 000 000 B ANY AUTO BODILY INJURY (Per person) $ -ALL OWNED 7 SCHEDULED 605036731 08/28/2011 08/28/2012 BODILY INJURY (Per acci dent) $ -AUTOS ~ ~~~?JWNED r--HIRED AUTOS -AUTOS iP~9~~d~gAMAGE $1 000 000 $ UMBRELLA LIAB H OCCUR EACH OCCURRENCE $ ,__ EXCESS LIAB CLAIMS -MADE AGGREGATE $ OED I I RETENTION $ $ WORKERS COMPENSATION ./ 1 -fo~~I~.I.~s I ID,J~-AND EMPLOYERS" LIABILITY YIN c ANY PROPRIETOR/PARTNER/EXECUTIVE w E.l. EACH ACCIDENT $1 000 000 OFFICER/MEMBER EXCLUDED? Y N/A 0004201856 10/12/2011 10/12/2012 (Mandatory in NH) E.L. DISEASE-EA EMPLOYEE $1 000 000 If yes , desaibe under DESCRIPTION OF OPER ATIONS below E.l. DISEASE-POLICY LIMIT $1 000 000 DESCRIPTION OF OPERATIONS /LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remari<s Schedule, if more space is required) The City of Cupertino and their officers, employees, representatives, volunteers, and agents shall be named as Additional Insured. _, CERTIFICATE HOLDER CANGE((A TKm ~ / I Cupertino City Hall tWJroe~:•m~oBEFOR' 10300 Torre Ave THE IRA 0 D TE~EOF; NOTI~.l W L BE DELIVERED IN Cupertino, CA 95014 ACCO / c \.J ~ Y A OVIa!Q.NS - AUTHORIZED REPRESENTATIVE I ACORD 25 (2010/05) © 1988-2010 ACORD CORPORATION. All nghts reserved. The ACORD name and logo are registered marks of ACORD J k SCOTTSDALE INSURA.NCE COMP.A_NY"® ENDORSEMENT NO. ____ _ ATTACHED TO A ND ENDORSEMENT I!FFJ:;CTIVE DATE FORM ING A PART OF (-12:01 A.M. STAND A RD TIME) NAM ED INSURED AGENT NO . POLIC Y NUMeER C I?S ltl336 96 08/0 1/2 011 ROXT E F OOD TRU CK L LC DBA : 04 U74 I THIS ENDORSEMENT CHANGES ~HE POLICY . PLEASE READ IT CAREFULLY. BLANKET ADD ITION t l INS U RED ENDORSEMENT This endorsement modifies i ~surance provided unde r the following : COMMERCIAL GENERAL LIABILITY COVERAGE PART I With respect to this endo rsement, SECTIO N II -WHO 'S AN I N SURED is amended to inc lude as an additional jn- sured any person or organization whom you are required to add as an additional insured on this policy under a w ~it­ ten contract, written agreement or written permit which must be: I a. Currently in effect or becoming effective durir g the term of the policy; and b . Executed p r ior to the "bodily inju ry ," "prope~ damage," or "personal and advertising injury f The insu rance provided to these additional insureds is li1[11 - ited as follows: 1. That person or organization is an additional In- sured only with respect to liability for "bod \iy injury," "property damage" or "personal and adver- tising injury" caused, in whole or in part, by : a. Your acts or omissions; or b . The acts or omissions of those acting on yolur behalf. A person 's or organization's status as an additional insured under this endorsement ends when your operations for that additional insured alre completed. 2. With respect to the insurance afforded to these ab - ditional insureds, the following exclusions alre added to item 2 . Exclusions of SECTION I - COVERAGES: This insurance does not apply to "bodily injurt ," "property damage" or ··personal and advertising in- jury" occurring ~fter: I a. All work, including materials, parts or equip- ment furnished in connection with such work , on the project (other than service, mainte- nance or repairs) to be performed by or on be- half o f the additional insured(s) at the location of the covered ope rations has been com- pleted ; or b . That portion of "your work" out of which the in- jury or damage arises has been put to its in- tended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a princi- pal as a part of the same project. 3. The limits of insurance applicable to the additional insured are those specified in the written contract, written agreement or w ritten permit or in the Dec la - rations for this policy, whichever is less. These lim- its of insurance are inclusive of. and not in additio n to , the Limits of Insurance shown in the Declara- tions for this policy. 4. Coverage is not provided fo r "bodily injury," "prop- erty damage," or "personal and advertising injury" arising out of the sole negligence of the additional insured . 5 . The insurance provided to the additional insured does not apply to "bodily injury," "property dam- age," or "pe rsonal and advertising injury" arising out of an architect's, engineer's o r surveyor's ren- dering of or failure to render any professional serv- ice~ including; Includes copyrighted m at erial ~f ISO Properties , Inc., with ils p ermission . GL&150s (7-06) Copyright , ISO Properties. Inc., 2004 !Page 1 of2 IN,URED a_ The preparing , approving or failing to prepare or approve maps. shop drawing$, op i nions, re - ports, surveys, tiell'l orders. change orders or drawings and s pecifications ; and D. Supervisory, inspection, architectural or engi- neering activities. 6. Any coverage provided hereunder will be excess over any other valid and collectible insurance avail- able to the additional insured whether primary, ex- cess, contingent or on any other basis unless a written contract specifically req1.1ire~ that this in5ur- ance be primary _ When this Insurance is exc ess, we will have no dl.l - ty under SECTION I-COVERAGES to defend the additional insured against any "suit" if any other in- surer has a duty to defend the additional insured against that "suit" If no other insurer defends, we will undertake t o do so , but we will be entitled to the additional insured's rights against all those oth- er insurers. I ~ Includes copyrighted material of ISO Properties , Inc., with its permission. Copyright , ISO Properties, Inc ., 2004 GLS-150s (7-06) Page2of2