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6.D. - Page 125 of 170 <br />PUBLRES-01 LBOSSHART <br />ACORD`' CERTIFICATE OF LIABILITY INSURANCE <br />DATE(MM <br />4/19/20162016YY) <br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS <br />CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES <br />BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED <br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. <br />IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to <br />the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the <br />certificate holder in lieu of such endorsement(s). <br />PRODUCER License # 0795135 <br />Armstrong/Robitaille/Riegle Business and Insurance Solutions <br />830 Roosevelt Avenue, Suite 200 <br />Irvine, CA 92620 <br />CONTACT <br />NAME: Lindsay Bosshart <br />PHONE (714) 221-3944 FAX No ; (714) 221-2277 <br />A/c No Ext <br />E-MAIL SS; Lbosshart@ar-ins.com <br />INSURER(S) AFFORDING COVERAGE NAIC # <br />INSURERA:Valley Forge Insurance Company 20508 <br />INSURED <br />The Public Restroom Company <br />2587 Business Parkway <br />Minden, NV 89423 <br />INSURER B:AmTrust Insurance Company of Kansas 15954 <br />INSURER C: Continental Casualty Company 20443 <br />INSURERD:Granite State Insurance Co 23809 <br />INSURER E: Evanston Insurance Company 35378 <br />INSURERF: <br />COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: <br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD <br />INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS <br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, <br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br />INSR <br />LTR <br />TYPE OF INSURANCE <br />ADDL <br />INSD <br />SUER <br />WVD <br />POLICY NUMBER <br />POLICY EFF <br />MM/DD/YYYY <br />POLICY EXP <br />MMIDD/YYYY <br />LIMITS <br />A <br />X COMMERCIAL GENERAL LIABILITY <br />EACH OCCURRENCE $ 1,000,000 <br />CLAIMS -MADE N OCCUR <br />6022751974 <br />12/24/2015 <br />12124/2016 <br />pREMISEs Ea occurrence $ 100,000 <br />MED EXP (Any one person) $ 15,000 <br />PERSONAL & ADV INJURY $ 1,000,000 <br />GEN'L AGGREGATE LIMIT APPLIES PER: <br />PROPOLICY � JEC FILOC <br />GENERAL AGGREGATE $ 2,000,000 <br />PRODUCTS -COMP/OPAGG $ 2,000,000 <br />$ <br />OTHER: <br />AUTOMOBILE <br />LIABILITY <br />EOMBII aeD nt)SINGLE LIMIT $ 1,000,000 <br />B <br />X <br />ANY AUTO <br />KPP102373301 <br />12124/2015 <br />12/24/2016 <br />BODILY INJURY (Per person) $ <br />ALL OWNED SCHEDULED <br />AUTOS AUTOS <br />BODILY INJURY (Per accident) $ <br />X <br />HIRED AUTOS X NON -OWNED <br />AUTOS <br />PROPERTY DAMAGE $ <br />Per accident <br />X <br />UMBRELLA LIAB <br />X <br />OCCUR <br />EACH OCCURRENCE $ 4,000,000 <br />C <br />EXCESS LIAB <br />CLAIMS -MADE <br />6022751988 <br />12/24/2015 <br />12/24/2016 <br />AGGREGATE $ 4,000,000 <br />DED X RETENTION $ 10,000 <br />$ <br />D <br />WORKERS COMPENSATIONOTH- <br />AND EMPLOYERS' LIABILITY <br />ANY PROPRIETORIPARTNER/EXECUTIVE YIN <br />OFFICER/MEMBER EXCLUDED? ❑ <br />(Mandatory In NH) <br />If yes, describe under <br />DESCRIPTION OF OPERATIONS below <br />N I A <br />04/01/2016 <br />04/01/2017 <br />I STATUTE ER <br />X PER013013907 <br />E.L. EACH ACCIDENT $ 1,000,000 <br />E.L. DISEASE- EA EMPLOYEE $ 1,000,000 <br />E.L. DISEASE -POLICY LIMIT $ 1,000,000 <br />E <br />Professional Liab <br />MAX7PL0001951 <br />08/28/2015 <br />08/28/2016 <br />Per Claim/Aggregate 2,000,000 <br />A <br />Builders Risk <br />6022751974 <br />12/24/2015 <br />12/24/2016 <br />Limit 1,000,000 <br />DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) <br />Policy #6022751974 - Includes Property in Transit Limit of $200,000/Deductible: $2,500. - <br />Certificate Holder is included as additional insured on the general liability on a primary non contributory basis as required by written contract per the <br />attached forms. Waiver of subrogation applies to the general liability and workers compensation per the attached forms as required by written contract. 30 <br />days written notice of cancellation except 10 days for non-payment of premium. <br />CERTIFICATE HOLDER CANCELLATION <br />©1988-2014 ACORD CORPORATION. All rights reserved. <br />ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD <br />208 <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />For Insured's Records <br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />Workers Compensation - CA <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />AUTHORIZED REPRESENTATIVE <br />��'-^PA0OVE <br />©1988-2014 ACORD CORPORATION. All rights reserved. <br />ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD <br />208 <br />