BREAK-1
OP ID: AF
DATE (MM/DD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE
01/18/2023
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).
CONTACT
NAME:
PHONE
(A/C, No, Ext): 415-820-2200
E-MAIL
ADDRESS:
PRODUCER
Pennbrook Insurance Services
License #0622553
142 Sansome Street, 4th Floor
San Francisco, CA 94104
Pennbrook - House A/C
FAX
(A/C, No):
415-394-8332
INSURER(S) AFFORDING COVERAGE
NAIC #
25895
INSURER A : United States Liability Ins Co
INSURED
Breakthrough Sushi/Cradix LLC
Mr. Kaz Matsune
100 Pine Street, Suite 1250
San Francisco, CA 94111
INSURER B :
INSURER C :
INSURER D :
INSURER E :
INSURER F :
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
LTR
A
TYPE OF INSURANCE
X
POLICY NUMBER
POLICY EFF
POLICY EXP
(MM/DD/YYYY) (MM/DD/YYYY)
COMMERCIAL GENERAL LIABILITY
CLAIMS-MADE
X
ADDL SUBR
INSD WVD
X
OCCUR
X
CL1664840D
01/20/2022 01/20/2023
Professional Liab
GEN'L AGGREGATE LIMIT APPLIES PER:
PROX POLICY
LOC
JECT
HIRED AUTOS
EACH OCCURRENCE
DAMAGE TO RENTED
PREMISES (Ea occurrence)
$
MED EXP (Any one person)
$
PERSONAL & ADV INJURY
$
$
PRODUCTS - COMP/OP AGG
$
$
COMBINED SINGLE LIMIT
(Ea accident)
BODILY INJURY (Per person)
SCHEDULED
AUTOS
NON-OWNED
AUTOS
$
GENERAL AGGREGATE
Prof Liab
OTHER:
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED
AUTOS
LIMITS
1,000,000
300,000
5,000
1,000,000
2,000,000
2,000,000
Included
$
$
BODILY INJURY (Per accident) $
PROPERTY DAMAGE
(Per accident)
$
$
X
A
UMBRELLA LIAB
X
EXCESS LIAB
EACH OCCURRENCE
OCCUR
CUP1554755F
CLAIMS-MADE
01/20/2022 01/20/2023
10,000
X RETENTION $
DED
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
Y/N
ANY PROPRIETOR/PARTNER/EXECUTIVE
N/A
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
$
AGGREGATE
$
2,000,000
2,000,000
$
PER
STATUTE
OTHER
E.L. EACH ACCIDENT
$
E.L. DISEASE - EA EMPLOYEE $
E.L. DISEASE - POLICY LIMIT
$
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
CERTIFICATE HOLDER
Hotel Kabuki
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.
AUTHORIZED REPRESENTATIVE
Pennbrook - House A/C
ACORD 25 (2014/01)
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