DATE (MM/DD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE
6/4/2022
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
PRODUCER
Leslie Goodfellow
NAME:
FAX
PHONE
Goodfellow Insurance, Inc
(A/C, No):
(A/C, No, Ext): 516 707 4997
E-MAIL
13 Veterans Memorial Hwy S 202
ADDRESS: Goodfellowleslie926@gmail.com
Hauppauge, NY 11787
INSURER(S) AFFORDING COVERAGE
NAIC #
1,000,000.00,
INSURER A : State Farm
INSURED
INSURER B :
Johanna Flores
51-02n103rd Street 2nd Floor
Corona, NY 11368
347 856 9189
COVERAGES
INSURER C :
INSURER D :
INSURER E :
INSURER F :
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
TYPE OF INSURANCE
ADDL SUBR
INSR WVD
POLICY NUMBER
POLICY EFF
POLICY EXP
(MM/DD/YYYY) (MM/DD/YYYY)
GENERAL LIABILITY
$
MED EXP (Any one person)
$
PERSONAL & ADV INJURY
$
GENERAL AGGREGATE
$
GEN'L AGGREGATE LIMIT APPLIES PER:
PROPOLICY
LOC
JECT
PRODUCTS - COMP/OP AGG
$
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
(Ea accident)
BODILY INJURY (Per person)
COMMERCIAL GENERAL LIABILITY
CLAIMS-MADE
A
LIMITS
EACH OCCURRENCE
DAMAGE TO RENTED
PREMISES (Ea occurrence)
OCCUR
Event Promotion
ANY AUTO
ALL OWNED
AUTOS
HIRED AUTOS
APR- 2750H2307
7/21/2021
7/21/2022
$
1,000,000
150,000
1,000,000
1,000,000
1,000,000
$
SCHEDULED
AUTOS
NON-OWNED
AUTOS
$
$
BODILY INJURY (Per accident) $
PROPERTY DAMAGE
(Per accident)
$
$
A
UMBRELLA LIAB
OCCUR
EXCESS LIAB
CLAIMS-MADE
WPR- 2725U3149
7/21/21
7/21/22
DED
RETENTION $ 25000
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
EACH OCCURRENCE
$
AGGREGATE
$
100,0001
1,000,000
$
WC STATUTORY LIMITS
OTHER
E.L. EACH ACCIDENT
$
E.L. DISEASE - EA EMPLOYEE $
E.L. DISEASE - POLICY LIMIT
$
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
Permotional Event- One Robot to preform on 6/4/22 @ CB Catering,71-46 Main Street, Flushing, NY 11367
CERTIFICATE HOLDER
CANCELLATION
CB CATERING, INC
71-46 Main Street
Flushing, New York 11367
Charismaballroom2@gmail.com 718 268 28008
ACORD 25 (2010/05)
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
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