We Sushi-Certificate of Insurance-2014A`40R" CERTIFICATE OF LIABILITY INSURANCE
DATE(MMID014W)
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:
COASTAL BROKERS INS SERVICES -QUESTIONS CONTACT
PHONE FAX
HONE
No Ext : LAIC, No):
RVIS INSURANCE
E-MAIL
ADDRESS:
INSURER(S) AFFORDING COVERAGE
NAIC*
1670 BERRYESSA RD
SAN JOSE CA 95133
INSURERA: BURLINGTON INSURANCE CO
INSURED
INSURERS
RODA API, LLC
2842 CLEMENT ST
INSURERC:
INSURER D
INSURERE:
SAN FRANCISCO CA 94121
INSURER F :
LS
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. NOTINITHSTAN DING 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
TR
OF INSURANCE
ADDLTYPE
INSR
WVDSUER
POLICY NUMBER
POLICY
VYVV
MM DW DIVV
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE
$ 1,000,000
x COMMERCIAL GENERAL LIABILITY
O HEN ED
PREMISEDAMAGE S EaocuDence
$ 100000
CLAIMS -MADE � OCCUR
Y
F
��
MED FAR (Any one person)
$ 5,000
PERSONAL & ADS INJURY
$ 1,000,000
A
846B002307
2-10-2014
2-10-2015
GENERAL AGGREGATE
$ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER'.
PRODUCTS - COMP/OPAGO
$2000000
x POLICY PRO LOC
JECT
$
AUTOMOBILE
LIABILITY
(—
(—
f
COMBINED SINGLE LIMIT
Ea accident
$
BO D I LY IN JU RY(Re r person)
$
ANY AUTO
11
ALL OMSCHEDULED
AUTOS AUTOS
BO D I LY IN JU RY(Re r accid ent)
$
NON-OVAED
HIRED AUTOS AUTOS(Per
PROPERTVDAMAGE
acadent
$
UMBRELLA LIAB
OCCUR
F,
EACH OCCURRENCE
$
AGGREGATE
$
EXCESS LIAB
CLAIMS -MADE
rrr
!!!
DED RETENTION$
$
WORKERS COMPENSATION
WC STATU- OTH-
ANDEMPLOVERS'LIABILITY YIN
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICE/MEMBER EXCLUDED?
NIA
TORY LIMITS ER
E L. EACH ACCIDENT
$
EL.DISEASE -EAEMPLOYE
$
(Mantlatoryin Mi)
If yes DESCRIPTION under
DESCRIPTION under
OPERATIONS below
EL.DISEASE-POLICY LIMIT
$
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
CERTIFICATE HOLDER AND THE CITY OF CUPERTINO AND THEIR OFFICERS, EMPLOYEES, REPRESENTATIVES AND AGENTS ARE ADDITIONAL
INSURED PER FORM BG-G-305
CERTIFICATE HOLDER
CUPERTINO CITY HALL
10300 TORRE AVE
CUPERTINO
CA 95014
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
jat�l, T - UL063-E.RPORATION.
All rights reserved.
ACORD 25 (2010/05)
The ACORD name and logo are registered marks of ACORD