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HomeMy WebLinkAboutAUTOMATED VENDING TECHNOLOGIES, INC. (AVT) 4B-2015City of Santa P -i Clerk of the Council AGREEMENT TERMINATION FORM Please complete this form in its entirety when the attached agreement and all amendments (if any) are no longer in effect. Note: If your agreement is grant related, please ensure that all grant retention requirements of Santa Ana have been satisfied prior to signing the termination form. 2y1 Is the agreement(s) a permanent record? Yes No — Return form to the Clerk of the Council Office (M-30). Clerk of the Council Call 647-1520 if you have any questions. The agreement with AkA--ny"(J" N�-y CW \-eWl'1()c)lcS No. 2J' 0C) was completed on UBMU and final payment has been made. (List all amendments. Use space below if needed.) PC-p�1 2� 01) -0 Department: MMAJ Pdm1t J oCi -t)a Phone/Ext.: , a at Signature: S�-Dr )Crl�elevan Date: -71,91 Revised: 10418-16 1 1NSONANCE..ON P1l.t:. WORK MAY PROCEED NTIL INSURANCE: EXPIRE"', CLERK OF C IINCII DATE: --6�5 -`5 EXERCISE OF SECOND OPTION EXTENSION OF VENDING AGREEMENT A-2013-091-02 THIS EXERCISE Or SECOND OP`l`ION - EXTENSIGN OF VENDING AGREEMENT is effective as of July 1, 2015, by and between Autornated Vending Technologies Inc., a Nevada corporation dba in California as Automated Vending Inc. (`Vendor"), and the City of Santa Ann, a charter city and municipal corporation organized and existing unifier the Constitution and laws of the State of California ("City") RECITALS A. The parties entered into the "Vending Agreement between the City of Santa Ana and Automated Vending Technologies In(,,." (# A-2013-091) dated July 1, 2013 ("Agreement") by which Vendor has provided beverage and/or snack vending machines at various City -owned properties. B. The initial term of the Agreement was for one year, and the City exercised its option to extend the Agreement for a second year, from July 1, 2014 through June 30, 2015, by prior written agreement, #A- 2013.091-01. C. In accordance with the terms and conditions of tho Agreement, the City wishes to exercise a second option to extend the Agreement for an additional year, THE PARTIES THEREFORE AGREE: 1. Section 1, TERM, shall be extended by one year, from July 1, 2015 th rough June 30, 2016. 2. A revised and updated list of vending machines and their locations is attacked hereto and incorporated herein as Exhibit A, which shall supersede any prior list. 3. Except as amended above, all terms and conditions of the Agreement shall remain in full force and effect. IN WITNESS WHEREOF, the parties hereto have executed this Second Option - Extension of Vending Agreement, as effective on the date and year fist written above. ATTEST: MARIA D. IITJILAR Clerk of the Council APPROVED AS TO FORM: SONIAR. CARVALHO City Attorney By: _ 94 YG i+ww Joh.q) Funk Assistant City Attorney CITI' " TA ANNA DAV /1'��$ City Manager VENDOR: Automated Vending Technologies Ilse. �L7n A I h President Parts, Recreation & Community Services Agency EXHIBIT A VENDING MACHINE LOCATIONS - EXISTING SITES PIZt...SA Park/Facility Sites Addi'ESS ExiSting Proposed Number/Type M-mbine Of Machines Memorial Park 2102 S. Flower St. 2 1 drink and I snack (PUBLIC) Rosita Park and Salgado 706 N. Newhope St. 2 1 drink and I snack Recreation Center (PUBLIC) Santa Ana Public Library 26 Civic Center Plaza 2 1 cold drink and 1 snack (EMPLOYEE) Santa Ana Senior Center (SASC) 434 W. 3"' Street 1 1 cold drink/snack combo (PUBLIC) Southwest Senior Center SWSC) 2.201 W. McFadden Ave. 2 1 cold drink and I snack (PUBLIC) E1 Salvador Park 1825 W Civic Center 2 1 cold drink and 1 snack Other City Agency Facility Address Existing Proposed Number/Type _J Sites Of Machines Santa Ana Regional —`--Machine 1000 East Santa Ana Blvd 3 2 cold drink and 1 snack Transportation Center (SAR.TC) (PUBLIC) Santa Ana Police Department, 60 Civic Center Plaza 3 1 cold drink, 1 hot drink, Code 7 Calis (EMPLOYEE) and I snack Santa Ana Police Department, 60 Civic Center Plaza 1 1 cold drink I" Floor (EMPLOYEE) Santa Ana City Hall 20 Civic Center Plaza 2 1 cold drink and I snack (EMPLOYEE) Santa Ana City Yard, 220 S. Daisy Ave. 2 1 cold drink and 1 snack _ Administrative Building (EMPLOYEE) 2 ") I I'/f - AliCCORbr CERTIFICATE OF LIABILITY INSURANCE 5/12/2014 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 Ts an ADDITIONAL INSURED, the policy(les) 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 NOW Century Insurance Services 16 N. 2nd Street Alhambra, CA 91801 NANEACT New Century Ins Srv, Inc. PN°NE.Exel• (626)300-9000 FAX Noll:(626)570-0908 EMAIL ._......._........_......__.. AODR :lft O(Jusnci.com / License No. OB07085 INSUREWID AFFORDING COVERAGE NAIC p INSURER A:American Fire and Casualty 4066 INSURED AVT, Inc. 341 Bonnie Circle Ste 102 Corona CA 92880 INSURERS Peerless Insurance Company 24198 INSURER C:National Union Fire_ Ins Cc Pa 19445 INSURERD:Foremost Signature Insurance Cc 41513 INSURER E : INSURER F: COVERAGES CERTIFICATE NUMBERsALL 14-15 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. INSft 1113. TYPE OF INSURANCE AD LSU R POLICY NMBER POLICY EFF IMMIDDNMt POLICY EXP JRMLPDX=LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES ELATED fee $ 500,000 A CLAIMS -MADE OCCUR 3KA55963427 /31/2014 /31/2015 MED EXP(Any one person) $ 5,000 PERSONAL &ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPfOP AGG $ 2,000,000 X POLICY PRO- LUC $ AUTOMOBILE LIABILITY COMBINE dEDt SINGLE LIMIT 1 000 000 X _adnB BODILY INJURY (Per parson) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BA2442759 /22/2014 /22/2015 BODILY INJURY (Per accident) $ HIRED AUTOS No OSWNED PPROPE dTYacc,DAMAGE $ $ X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 4,000,000 AGGREGATE $ 4,000,000 L• EXCESS LIAR CLAIMS -MADE DED I I RETENTION $ BU063717909 11/412013 1/4/2014 D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOP/PARTNERIEXECUTIVE ❑ OFFICERIMEMBER EXCLUDED? (Mandatory in NH) NfA 04007748 f6/2014 j6/2015 WC STATD- Ol'H- X 1 E.L. EACH ACCIDENT $ 11000,000 E.L. DISEASE EA EMPLOYEE $ 1,000,000 If Yes, describe under DESCRIPTION OF OPERATIONS below ..—.---.....___..__...._._. E.L. DISEASE POLICY LIMIT $ 1 000 000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) THE CITY OF SANTA ANA, ITS OFFICERS, EMPLOYEES, AGENTS, VOLUNTEERS AND REPRESENTATIVES ARE NAMED AS ADDITIONAL INSURED PER POLICY FORM NUMBER: CG70020101. THIS CERTIFICATE IS VALID ONLY IF THE CERTIFICATE HOLDER REQUIRES IN A WRITTEN CONTRACT TO BE NAMED AS ADDITIONAL INSURED. THIS POLICY IS PRIMARY 4 NON-CONTRIBUTORY. 10 DAYS NOTICE OF CANCELLATION FOR 112N PAYMENT OF PREMIUM. 30 DAYS OTHERWISE. ,TO TOVIV, (714)571-4211 The City of Santa Ana Parka, Recreation and 20 Civic Center Plaza P.O. Box 1988 Santa Ana, CA 92702 4tar G�{y ^`- P5St5tatt Community Services M-23 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Shen/BIH 9)1988-2010 ACORD CORPORATION. All rinhts reserved. INSn25r9Mnmsint Thu AChRn nemu and Innn oru runicfaruA enerke of Arnion COMMERCIAL GENERAL LIABILITY CG 88 83 04 12 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. AMENDMENT OF OTHER INSURANCE CONDITION - DESIGNATED PERSONS OR ORGANIZATIONS This endorsement modifies insurance provided under the following: am= COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): CITY OF SANTA ANA, ITS OFFICERS, -- EMPLOYEES, AGENTS, AND Address 26 CIVIC CENTER PLAZA s City State Zip SANTA ANA, CA 92701 (Information required to complete this Schedule, if not shown above, will be shown in the Declarations.) With respect to coverage afforded by this endorsement, the provisions of the policy apply unless modified " by the endorsement. A. The following is added to Paragraph a. Primary Insurance of Condition 4. Other Insurance under Section IV -Commercial General Liability Conditions: However, when the person or organization shown in the Schedule of this endorsement has been added as an additional insured to this Coverage Part by attachment of an endorsement, we will not seek contribution from the "person's or organization's own insurance" provided that: (1) You have agreed in a written contract that this insurance is primary and non-contri butory; and (2) The "bodily injury", "property damage" or "personal and advertising injury" is: a. Committed subsequent to the execution of such contract; and b. This policy covers the "bodily injury", "property damage" or "personal and advertising in- jury". B. For the purposes of this endorsement the following is added to Section V - Definitions : "Person's or organization's own insurance" means general liability coverage for damages for which the person or organization shown in the Schedule of this endorsement is designated as a Named Insured. APPROVED AS TO FORM © 2012 Liberty Mutual insurance'' aL A E. STRadCK 0 CG 88 83 04 12 Includes copyrighted material of Insurance Services Office, Inc., with its per mlSssi ISA City RCK, MnO 1 General Endorsement POLICY NUMBER OKA )15) 55963427 Policy Period: From 05/31/2014 To 05/31/2015 12:01 am Standard Time at Insured Mailing Location o This Endorsement Changes The Policy, Please Read it Carefully, THE FOLLOWING APPLIES TO FORM C08883 - AMENDMENT OF OTHER INSURANCE - DESIGNATED PERSONS OR ORGANIZATIONS: COMPLETE ADDITIONAL INSURED: CITY OF SANTA ANA, ITS OFFICERS, EMPLOYEES, AGENTS, AND REPRESENTATIVE PARKS, RECREATION AND "s COMMUNITY SERVICES AGENCY 8 26 CIVIC CENTER PLAZA SANTA ANA, CA 92701 To report a claim, call your Agent or 1.800-362-0000 CG 70 02 0101 APPROVED AS TO PO'RT4 Page 1 of 2 SA E, STORCS Assistant City Attarney 3/ 3 ,` CERTIFICATE OF LIABILITYINSURANCE �A��2M��lr�YYYY) 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 doe's not confer rights to the certificate holder in lieu of such ondorsoment(s). PRODUCER CONTACT New Century Ins Srv, Inc,. NAME: New Century Insurance Services PHaNE Q625)3aa-9aaa (AC. N©:(E26)570-0908 16 N. 2nd Street E-MAIL ADDRESS: in£a@usnc .eam ,✓ License No. aB07085 INSURERS AFFORDING COVERAGE NAIC # Alhambra, CA 91801 INSURERA:Ohio SecurityInsurance Com am 4082 _._ . ._ .. _...... - INSURED AAA ,-,,` )131 (` l-(, NSURERBAmerican Fire and Casualty CO 24066 AVT, Inc. INSURERCNational Union Fire Ins Co Pa 19445 341 Bonnie Circle Ste 102 INSURER D:Hartford Insurance Co. Of The 37478 INSURER E :.. ...._. __...__..- Carona CA 92880 INSURER I=: C0VFRACFS CFRTI'FIrATF N141i RFR•ALL 15-16 UMS 14-15 RPVICI()N NI INIRPI:P• 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-__,.... ADDL..SUBR EFF.._ POLICY EXR, mm .....___.......... . LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER. MMIDDYYYY MMIODfYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE OmR"C TED--- PREMISES Ea occurrence _. $ 500,000 A '., CLAIMS -MADE F OCCUR KS (16) 55963427 /31/2015 5/31/2016 MED EXP (Any one person) $ 15,000 PERSONIAL & ADV INIURY $ 1,000,000 .GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMITAPPLIES PER_m..m.._ -GENERAL - COMPIOP AGG $ 2,000,000 X POLICY ''',, PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident 1 04a (Pl7a r_.._..... � ANY AUTO _ BODILY INJURY (Per parson) ...$...,.._.. .c.__.-_.._- $ g ALL OWNED SCHEDULED AUTOS AUTOS AA 1 7 ( 6)5596342 /22/2015 2/22/2016 .._ BCDILYINJLIR'Y(Peraccfident) $ WON-OWNIED —PROPERTYDAMAGE $ FIRED AUTOS AUTOS -Inderinsured motorists $ 1,000,000 .X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 4,000,000 AGGREGATE .--...__.___...,...-.......�-.._w._._.... $ 4,000,000 C EXCESS LIAR CLAIMS -MADE -..i. DED RETENTION $ EBU020447604 11/4/2014. 11/4/2015 D WORKERS COMPENSATION VVC STATU- OTH- X AND EMPLOYERS' (.(ABILITY Y f N T Y_I.it�IP.T.S. _-_.. ANY PROMEMRERfEXCLUCRrEKECUTIVE E.L..EACHACCIDENT. $ 1 000 000 aFFtlCER�MEMEER EXCLUCED? (Mandatary in NH) N f A 72TnTECVEC5513(Y /6/2015 /6/2016 E.L. DISEASE - EA EMPLOYE( $ 1,000,000 '.. It yes., describe under .................. DESCRIPTION OF OPERATIONS deYow ...._. E.L. DISEASE - POLICY LIMIT $ 1 000 000 DESCRIPTION OF OPERATIONS 1 LOCATIONS f VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) THE CITY OF SANTA.ANA, ITS OFFICERS, EMPLOYEES, AGENTS, VOLUNTEERS AND REPRESENTATIVES ARE NAMED AS ADDITIONAL INSURED PER POLICY FORM NUMBER. CG88830412. THIS CERTIFICATE IS VA11D ONLY IF THE CERTIFICATE HOLDER REQUIRES IN A WRITTEN CONTRACT TO BE NAMED AS ADDITIONAL INSURED, THIS POLICY IS PRIMARY & NON-CONTRIBUTORY. la DAYS NOTICE OF fi LLATION FOR NON PAYMENT OF PREMIUM. 30 DAYS OTHERWISE. (714) 571-4211 0sGvu (.\ The City of San Ana Parks, Recreation and C mmunity Services 20 Civic Center Plaza M-23 P.O. Boat 1988 Santa Ana, CA 92702 UA,NLI=LLA I IUN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE, Yang Qiao/YINQIA ACORD 25 (2010105) 01988-2010 ACORD CORPORATION, All rights reserved. INS029;l�ninn,a n1 Thn Ar`.OPn nnma and I'nnn nra ranieffarari mneke off A(`r)0r5 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ |TCAREFULLY. __--- This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE ----- Name Of Additional Insured Pereon(m)0rOrgan izmtinw(m): � czzy OF oamra AmA : PARKS, RECREATION AND coMMomzzz Address zo Czvzc comzsR PLAZA M-23 P.O. oox zean City State Zip SAmTA 4mA, CA 92781 (Information required to complete this 8chedula, if not shown above, will be shown in the Declarations.) With respect to coverage afforded by this endorsement, the provisions of the policy apply unless modified - bythe endorsement. A. The following is added to Paragraph a. Primary Insurance of Condition 4. Other Insurance under Section IV -Commercial Eieoena| Liability Conditions: Howmvar, when the person or organization shown in the Schedule of this endorsement has been added as an additional insured to fte Coverage Part by attachment of on emdoraament, we will not seek contribution from the ^person's oror0amizuhon'a own inoumamoo° provided that: (1) You have agreed in avuhtten contract that this insurance is primary and nwn'oontri bu0ory; and (2) The "bodily injury". "property damage" or "personal and advertising injury" is: a. Committed subsequent to the execution of such contract; and b. This policy covers the "bodily injury", "property damage" or '^penmmaJ and advertising in- � jury~ B. For the purposes of this endorsement the following is added to Section V -Oefmdiomm � "Person'a ororganizadon`o own insurance" means general liability coverage for damages for which the � person or organization shown in the Schedule of this endorsement is designated as Named Insured. @ 2012 Liberty Mutual Insurance 10�Coverage is Provided In: Policy Number: Lgb1E:'"1 Ohio Security Insurance Company - a stack company BKS (16) 55 96 34! 27 �VIT. Z71. Policy Period: INSURANCE From 05/31/2015'To 05/31/2016 12:01 am Standard Time at Insured Whiling Location Common Policy Declarations Named Insured AVT INC SUMMARY OF LOCATIONS (626)300-9000 NEW CENTURY INSURANCE SVS INC This policy provides coverage for the following under one or more coverage parts. Please refer to the individual Coverage Declarations Schedules, or, the individual Coverage Forms for locations or territory definition for that specific Coverage Part, 0001 341 Bonnie Cir Ste 102, Corona, CA 92880-2895 0002 341 Bonnie Cir Ste 101-A, Corona, CA 92880-2895 0003 231 N Sherman Ave, Corona, CA 92882-1844 0004 119 N Maple St Ste P„ Corona, CA 92880-6998 This section lists the Forms and Endorsements for your policy. Refer to these documents as needed for detailed information concerning your coverage. FORM NUMBER TITLE CG 00 01 04 1.3 Commercial General Liability Coverage Form - Occurrence CG 04 36 04 13 Limited Product 'Withdrawal Expense Endorsement CG 20 11 04 1.3 Additional Insured - Managers Or Lessors Of Premises CG 20 28 04 13 Additional Insured - Lessor Of Leased Equipment. CG 21 06 05 1.4 Exclusion - Access Or Disclosure Of Confidential Or Personal Information And Data -Related. Liability - With Limited Bodily Injury Exception CG 21 47 1207 Employment -Related Practices Exclusion CG 21 65 12 04 Total Pollution Exclusion with a Building Heating, Cooling and Dehumidifying Equipment Exception and a Hostile Fire Exception CG 21 67 12 04 Fungi or Bacteria. Exclusion CG 21 70 01 08 Cap on Losses From Certified Acts of Terrorism CG 21 76 01 08 Exclusion of Punitive Damages Related to a. Certified Act of Terrorism In witness whereof, we have caused this policy to be signed by our authorized officers. I r a 0"504.w.m Dexter Legg Paul Condrin(' Secretary President To report a claim, call your Agent or 1-800 362-0000 DS 70 21 01 08 05101115 55963427 N0197371 275 GCXOPPNO INSURED COPY 000496 PAGE 28 OF 2,12 Coverage Is Provided In: Policy Number: L berty Ohio Security Insurance Company - a stag company BKS (16) 55 96 34 27 I'.L1tLic�IG Policy Period: INSURANCE From 05/31/2015 To 05/31/2016 Common Policy Declarations 12:01 am Standard Time at Insured Mailing Location Named Insured Agent AVT INC (626) 300-9000 NEW CENTURY INSURANCE SV'S INC POLICY FORMS AND ENDORSEMENTS CONTINUED This section lists all of the Forms and Endorsements for your policy. Refer to these documents as needed for detailed information concerning your coverage. FORM NUMBER TITTLE CG 21 88 01 07 Conditional. Exclusion of Terrorism Involving Nuclear, Biological or Chemical Terrorism (Relating to Disposition of Federal Terrorism Risk Insurance Act) CG 24 04 05 09 Waiver of Transfer of Rights of Recovery Against Others to Us CG 24 26 04 13 Amendment of Insured Contract Definition CG 32 34 01 05 California Changes CG 84 9901 12 Non -Cumulation Of Liability Limits Same Occurrence CG 88 10 04 13 Commercial General Liability Extension CG 88 60 1208 Each Location General Aggregate Limit CG 88 62 04 13 Additional Insured - Blanket Venders CG 88 77 12 08 Medical Expense At Your Request Endorsement CG 88 83 04 12 Amendment of Other Insurance Condition - Designated Persons or Organizations CG 88 86 12 08 Exclusion - Asbestos Liability CG 89 98 04 1.2 Amendment of Other Insurance Condition CG 90 41 01 13 Amendment Of Coverage B Personal And Advertising Injury CL 01 00 03 99 Common Policy Conditions CL 01 62 1.0 1.3 Amendatory Endorsement - California CL 06 00 01 08 Certified Terrorism Loss CL 07 00 10 06 Virus or Bacteria Exclusion CL 16 60 06 06 Conditional Nuclear, Biological, And Chemical Terrorism Exclusion - (With Limited Exception) CP 00 10 0402 Building and Personal Property Coverage Form CP 00 30 04 02 may' Business Income (and Extra Expense) Coverage FormwQ 9 CP 00 90 07 88 Commercial Property Conditions 'tie CP 01 40 07 06 Exclusion of Loss Due to Virus or Bacteria �+ a Changes Replacement Cost CP 04 49 12 05 California - CP 10 30 0402 Causes of Loss - Special Form CP 10 32 08 08 Water Exclusion Endorsement CP 12 18 0695 Loss Payable Provisions ,Q - CP 70 02 01 01 General Endorsement CP 72 97 0402 Equipment Breakdown Enhancement Endorsement - Special Form To report a claim, call your Agent or 1-800-362-0000 ©S 70 21 01 08 05/01/15 55963427 N0197371 275 GCXOPPNO INSURED COPY 000496 PAGE 29 OF 212 Coverage Is Provided In: Policy Number: Liberty Ohio Security Insurance Company - a stock company BKS (16) 55 96 34 27 Mutual ® Policy Period: INSURANCE From 05/31/2015 To 05/31/2016 Common Policy Declarations 12:01 am Standard Time at Insured Mailing Location Named Insured Agent AVT INC (626) 300-9000 NEW CENTURY INSURANCE SVS INC POLICY FORMS AND ENDORSEMENTS - CONTINUED This section lists all of the Forms and Endorsements for your policy. Refer to these documents as needed for detailed information concerning your coverage. FORM NUMBER TITLE CP 88 04 03 10 Removal Permit CP 90 55 12 12 Business Income And Extra Expense Changes - Actual Loss Sustained In A Twelve -Month Period CP 90 59 12 12 Identity Theft Incident Administrative Services and Expense Coverage CP 99 93 10 90 Tentative Rate IL 00 17 11 98 Common Policy Conditions IL 00 21 09 08 Nuclear Energy Liability Exclusion Endorsement (Broad Form) IL 01 02 05 05 California Changes - Actual Cash Value IL 01 04 09 07 California Changes IL 02 70 09 12 California Changes - Cancellation and NonRenewal IL 04 15 04 98 Protective Safeguards IL 09 35 07 02 Exclusion of Certain Computer -Related Losses IL 09 52 03 08 Cap on Losses From Certified Acts of Terrorism IL 09 96 01 07 Conditional Exclusion of Terrorism Involving Nuclear, Biological or Chemical Terrorism (Relating to Dispostion of Federal Terrorism Risk Insurance Act) IM 20 09 12 04 Amendatory Endorsement - California IM 75 00 04 04 Scheduled Property Floater LC 87 10 05 00 Punitive or Exemplary Damages Exclusion To report a claim, calf your Agent or 1-800-362-0000 DS 70 2101 08 05/01/15 55963427 N0197371 275 GCXOPPNO INSURED COPY 000496 PAGE 30 OF 212