Sams Chowder-Certificate of Insurance-2012ACORU. CERTIFICATE OF LIABILITY INSURANCE L 349949019
DATE(MM/DD/YYYY)
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Joe Angelini Insurance Agency HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
435 Johnston St ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Half Moon Bay CA 94019
INSURERS AFFORDING COVERAGE NAIC#
INSURED Half Moon Bay Catering LLC INSURER A:
INSURER B:
4210 Cabrillo HWY INSURER C:
Half Moon Bay, CA 94019 INSURER D:
INSURER E:
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
DD•L
NSRD
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
DATE MM/DD/YY
POLICY EXPIRATION
DATE MM/DD/YY
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE
$
COMMERCIAL GENERAL LIABILITY
PREMISES Eaoccurence
$
MED EXP (Anyone person)
$
CLAIMS MADE lx] OCCUR
PERSONAL& ADV INJURY
$
110001000
A
CPS1446477
11/28/11
11/28/12
GENERAL AGGREGATE
$
GENT AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGG
$
ri POLICY PRO-
JECT LOC
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT
$
ANYAUTO
(Ea accident)
1,000,000
ALL OW NED AUTOS
BODILY INJURY
$
SCHEDULED AUTOS
(Per person)
B
HIRED AUTOS
604746108
06/18/11
06/18/12
BODILYINJURY
NON-OWNEDAUTOS
(Peraccident)
$
PROPERTY DAMAGE
$
(Peraccident)
GARAGE LIABILITY
AUTO ONLY -EA ACCIDENT
$
ANYAUTO
OTHERTHAN EA ACC
$
$
AUTOONLY: AGG
EXCESS/UMBRELLA LIABILITY
EACH OCCURRENCE
$
9400 On
OCCUR CI CLAIMSMADE
AGGREGATE
$
$
XBS0018892
11/28/11
11/28/12
$
A
X
DEDUCTIBLE
RETENTION $
$
WORKERSCOMPENSATION AND
WCSTATU- OTH-
EMPLOYERS' LIABILITY
TORYLIMITS ER
E.L. EACH ACCIDENT
$
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
E.L. DISEASE - EA EMPLOYE
$
Ifyes, describe under
E.L. DISEASE - POLICY LIMIT
$
SPECIAL PROVISIONS below
OTHER
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS
"The City of Cupertino and their officers, employees, representatives,
volunteers, and agents shall be named as additional insured.11
Cupertino City Hall
10300 Torre Ave
Cupertino Ca 95014
k./YIVL,r—LLH 1 IUIV
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL '40 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO T E LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY O AN I D ON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
ACORD25 (2001 /08)
ACORD CORPORATION 1988
POLICY NUMBER: 604746108
COMMERCIAL AUTO
CA 20 48 02 99
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
DESIGNATED INSURED
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
GARAGE COVERAGE FORM
MOTOR CARRIER COVERAGE FORM
TRUCKERS COVERAGE FORM
With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless
modified by this endorsement.
This endorsement identifies person(s) or organization(s) who are "insureds" under the Who Is An Insured Provi-
sion of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form.
This endorsement changes the policy effective on the inception date of the policy unless another date is indi-
cated below.
Endorsement Effective: Countersigned By:
Named Insured:
HMB CATERING TRUCK LLC — (A horized Representative)
SCHEDULE
Name of Person(s) or Organization(s):
THE CITY OF CUPERTINO AND THEIR OFFICERS, EMPLOYEES, REPRESENTATIVES, VOLUNTEER
AND AGENTS SHALL BE NAMED AS ADDITIONAL INSURED."
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations
as applicable to the endorsement.)
Each person or organization shown in the Schedule is an "insured" for Liability Coverage, but only to the extent
that person or organization qualifies as an "insured" under the Who Is An Insured Provision contained
in Section II of the Coverage Form.
CA 20 48 02 99 Copyright, Insurance Services Office, Inc., 1998 Page 1 of 1 0