Business Alliance Insurance Company
Agency: Tagrisk Llc
Fax: (714) 902-1748
DBA: La Villa Mexican Food Restaurant
Application ID: 364841
Subject: UNDERWRITING CONFIRMATION
Date: 4/9/2015
* Your bind request will be rescinded if we do not receive all the following within ten (10) days of your
requested binding date. The effective date of the policy will be changed to the date that BAIC receives all
the following:
Remarks:
Conditions to bind coverage:
1) The required deposit check including inspection fee. 2) The application must be signed by both broker and insured.
3) Insured and Broker must both sign the No Loss Statement if there are no declared losses/claims for the past five (5) years. * THIS IS A REVISE QUOTE FOR RESTAURANT RISK -
Building coverage $220,000 Business Property $60,000 Business Income $100,000 other details per Proposal page.
. Loss Control inspection fee has been reduced to $150 from standard CLP fee $250. .
* General Exclusions & Conditions:
Additional General Exclusions: Abuse or Molestation Exclusion, Asbestos Liability Exclusion, Cross Suits, ADA Exclusion, Lead Exclusion, Designated Premises endorsement, Mold Liability Exclusion, Total Pollution Exclusion endorsement, War and Terrorism Exclusion
* Special Limitations and restrictions if applicable:
* THEFT EXCLUSION. (PROTECTIVE SAFEGUARDS ENDORSEMENT DOES NOT APPLY TO THIS RISK.)
25% Minimum Earned Premium No Flat Cancellation
* Deposit due 10 days from Effective Date *
This quote expires 45 days from the date above. BAIC reserves the right to withdraw this quote prior to binding. Please sign and mail back with the rest of the documentation if offer is accepted
Underwriter's Signature: Return Fax: 6508663987
The undersigned have read the proposal and the above conditions, is hereby agreed to accept the requirements.
Effective Date Requested:
_____________________________________________Broker Signature:
_____________________________________________The above bind order is acknowledged by _______________________, Date: __________.
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Bind offer is rescinded retro to effective date because Item(s) ___________ is (are) not received.
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Business Alliance Insurance Company
Proposal
Application ID: 364841 Proposal Date: 4/9/2015 12:47:45 PM
Proposed Insured: Agency Information: Lic #: 0I19313 John Gardner & Maria Gardner Tagrisk Llc
La Villa Mexican Food Restaurant Tagrisk Insurance Services, Llc
15333 Crenshaw Blvd 7755 Center Ave., #605
Gardena, CA 90249-4050 Huntington Beach CA, 92647
Phone: 3106753393 Fax: Phone: 8884751553 Fax: 7149021748 E mail: maria.lavilla84@gmail.com E mail: eschmidt@tagrisk.com
Property Coverages
Location: 15333 Crenshaw Blvd, , Gardena, CA, 90249-4050
Type Cause of Loss Amount Coinsurance Deductible Premium
Building Excl Theft $220,000 90% $1,000 $533
Business Personal Property Excl Theft $60,000 90% $1,000 $138
Business Income Excl Theft $100,000 25% $278
Extra Expense Excl Theft $25,000 40/80/100% $1,000 $118
Newly Acquired Property Excl Theft Per Form 90% $1,000 Included Property Off Premises Excl Theft $10,000 90% $1,000 Included
Personal Effects Excl Theft $2,500 90% $1,000 Included
Includes Extended Period of 30 days
Location: 15337 - 15339 Crenshaw Blvd, , Gardena, CA, 90249-4050
Type Cause of Loss Amount Coinsurance Deductible Premium
Building Excl Theft $262,500 90% $1,000 $635
Business Personal Property Excl Theft $20,000 90% $1,000 $74 Newly Acquired Property Excl Theft Per Form 90% $1,000 Included Property Off Premises Excl Theft $10,000 90% $1,000 Included
Personal Effects Excl Theft $2,500 90% $1,000 Included
Includes Extended Period of 30 days
Crime Coverages NONE NONE
Location : 15333 Crenshaw Blvd, , Gardena, CA, 90249-4050
Type Limit Deductible Premium
Money and Securities $1,000 $250 $50
Inland Marine NONE NONE
Location : 15333 Crenshaw Blvd, , Gardena, CA, 90249-4050
Type Limit Deductible Premium
Accounts Receivable $15,000 $1,000 $50
Valuable Papers $15,000 $1,000 $50
Liability Coverages
Coverage Type Deductible Occurrence Aggregate Premium
Premises & Operations $0 $1,000,000 $2,000,000 $3,528
Personal Injury* $0 $1,000,000 $2,000,000 Included
Advertising Injury* $0 $1,000,000 $2,000,000 Included
Products and Completed Operations $0 $1,000,000 $1,000,000 $590 Fire Damage Legal Liabilty (any one Fire)* $0 $50,000 Included
Medical Payments (per person) $0 $5,000 Included
Coverage Description Occurence /
Aggregate
Coverage Perils
Deductible Premium
LIQUOR LAW LIABILITY 1,000,000 / 1,000,000 PER FORM $0 $150
Description of operations Code Basis Exposure Restaurants - alcohol less than 30% receipts - table service 16910 S $400,000 Location : 15312 Eriel Ave, , Gardena, CA, 90249-4020
Additional Insured: 1 $29
Description of operations Code Basis Exposure
Parking - private 46622I A 1080
Location : 15337 - 15339 Crenshaw Blvd, , Gardena, CA, 90249-4050
Description of operations Code Basis Exposure
Warehouses - private 68706I A 1750
*Coverages included in Occurence and Aggregate Limits Sub Total Premium: $6,323 Inspection Fee: $150 Total Premium: $6,473
Business Alliance Insurance Company Broker Copy
To: Tagrisk Llc BAIC Representative: Alice Yang
DBA: La Villa Mexican Food Restaurant Telephone: 6508663999 Fax: Quote ID: 364841 Fax: 6508663987 Date: 4/9/2015
We are pleased to offer you the coverage per the attached based on the information provided. Please examine the coverage carefully. It may not be the same as the one you had applied for. The invoice total of $6,473.00 (plus $25.00 if option two is selected), includes our premium quotation of $6,473.00, a Ciga Fee of $0.00, and a fully earned inspection fee of $150.00. Any Fac Re amount is fully earned at inception.
Binding Offer and Payment Plan Please check one of the following options:
All fees, with the exception of prorated Ciga fee, are non-refundable Option I: Agency Bill g
f e d
c gfedcOption II: Installment Plan
Premium $6,323.00 $6,323.00
State Ciga Fees $0.00 $0.00
Inspection Fees $150.00 $150.00
Installment Set up Fees
(applies only to Option II) $25.00
Total Premium & Fees $6,473.00 $6,498.00
Minimum Facultative Charge $0.00 $0.00
Client Down payment Due
Broker $1,730.75 $1,755.75
Broker Commission: 15% $948.45 $948.45
Broker Deposit Due BAIC $1,730.75 $807.30
Balance Net of Commission
After Deposit $3,793.80 $4,742.25
(Due Within 30 Days From Effective
Date) (See Payment Schedule)
Minimum Earned, Retained
Premium and Fees $1,730.75 $1,755.75
25% Minimum Earned Premium No Flat Cancellation
Deposit Due Ten (10) Days From Effective Date
Broker Acceptance: __________________________________________ Date: ______________ Remarks:
Business Alliance Insurance Company
1111 Bayhill Drive, Suite 410 San Bruno, CA 94066
Phone: 650-866-3999 Fax: 650-866-3987
Name of Insured: John Gardner & Maria Gardner Quote ID: 364841
DBA: La Villa Mexican Food Restaurant Effective Date: 4/9/2015
Option II: Company Installment Payment Plan Total Premium Fees and Ciga: $6,498.00
Premium: $6,323.00
Inspection Fee $150.00
Minimum Premium $1,580.75
Ciga Fee $0.00
Installment Set-up Charge $25.00
Total Down Payment Due to Broker $1,755.75
Remaining Balance (due in 9 payments) $4,742.25
Monthly Payment (includes $10.00 Installment Fee) $536.92
Payment Schedule
Payment Amount Due Balance Due Date Payment Amount Due Balance Due Date
#1 $536.92 $4,295.33 6/9/2015 #6 $536.92 $1,610.75 11/9/2015 #2 $536.92 $3,758.42 7/9/2015 #7 $536.92 $1,073.83 12/9/2015 #3 $536.92 $3,221.50 8/9/2015 #8 $536.92 $536.92 1/9/2016 #4 $536.92 $2,684.58 9/9/2015 #9 $536.92 $0.00 2/9/2016 #5 $536.92 $2,147.67 10/9/2015 Important Notice:
1) The Premium Balance may be paid off any time before the due date.
2) After the 2nd cancellation, the policy will not be reinstated unless the premium is paid in full. 3) The billing invoice is sent to the insured directly.
4) If payment is received after the cancellation date, a $25 fee will be charged if the policy is reinstated. 5) The policy will be cancelled 10 days after the due date if payment is not received.
Insured's Signature: Broker's Signature:
Print Name: Date: Print Name: Date:
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
PROTECTIVE SAFEGUARDS
The following is added to Businessowners’ Special Property
Coverage form MVP 001 0902:
1. As a condition of this insurance, you are required to
maintain the protective devices in the covered location
2. The protective safeguards to which this endorsement
applies:
Burglar Alarm that is connected to a
central station protecting your business
We will not pay for loss or damage caused by or resulting from a
Theft and/or Burglary loss, if you:
1. Knew of any suspension or impairment in any protective
safeguards and failed to notify us of that fact; or
2. Failed to maintain any active protective safeguards in
proper working order.
All other policy terms and conditions remain unchanged.
Insured's
Name
Please print
Insured's
Signature
Date:
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
PROTECTIVE SAFEGUARDS
The following is added to Businessowners’ Special Property
Coverage form MVP 001 0902:
1. As a condition of this insurance, you are required to
maintain the protective devices in the covered location
2. The protective safeguards to which this endorsement
applies:
Burglar Alarm that is connected to a
central station protecting your business
We will not pay for loss or damage caused by or resulting from a
Theft and/or Burglary loss, if you:
1. Knew of any suspension or impairment in any protective
safeguards and failed to notify us of that fact; or
2. Failed to maintain any active protective safeguards in
proper working order.
All other policy terms and conditions remain unchanged.
Insured's
Name
Please print
Insured's
Signature
No Loss Statement
To:
Business Alliance Insurance
Company
Date: _____________
From
(DBA)
: Phone: _____________
Address:
This is to certify that there has been no loss or claim of any kind whether
insured or not for the last five (
5)
years or ever since we opened for business.
The undersigned understood and agree that the insurance contract is voided
from inception date if the above statement is untrue.
Insured’s signature: X_______________________ Title:______________
Date: _______________
This is to certify that the undersigned is the broker of record has explained the
above statement to the insured. The insured understood and agreed that the
document will be binding.
Broker’s signature: X_________________________
Date: _______________
BAIC Insurance Application General Information
Requested Effective Date: 4/9/2015 Date/Time Entered: 4/3/2015 10:58:28 AM Doing Business As: La Villa Mexican Food Restaurant
Entity Name: John Gardner & Maria Gardner Type Of Business:
First Named Insured: Type Of Operation:
Primary Contact Name: John Gardner Type Of Entity: Partnership Additional Partners/Owners: John Gardner & Maria Gardner
Mailing Address:
15333 Crenshaw Blvd Gardena (Los Angeles County), CA 90249-4050
Phone Number: (310) 675-3393 Email Address: maria.lavilla84@gmail.com Fax Number:
Location - 15333 Crenshaw Blvd Property Information
Risk Location Address:
15333 Crenshaw Blvd Gardena (Los Angeles County), CA 90249-4050
Description of Operations: Mexican family style restaurant with full bar; 24% alcohol sales Open from 11am-9pm No entertainment
Optional Coverage
Accounts Receiveable Amount: $15,000
Valuable Papers Amount: $15,000 Valuable Papers Deductible: 1000 Computer Data Amount: $0
Computer equipment Amount: $0 Computer Deductible: 1000
General Equipment Amoount: $0 General Equipment Rate per 100: 0.00% Inland Marine
Inside Sign Amount: $0 Outside Sign Amount: $0
Sales
Gross Sales: $400,000 Total Alcohol Sales: $0
Money and Securities
Money and Securites Amount: $1,000 Class C Safe: No
Structure
Property Description
Property Type: Normal Building Sprinkled: No Type Of Construction: Frame Year Built: 1950
Total Area: 1350 sq. ft. Occupied Area: 1350 sq. ft.
Open Sided: No Owner Occupied: Yes
Number of Like Structures: 1 Alarm Type: None CSP Code: 0542
Property Coverage
Building: $220,000 Contents: $60,000
Income: $100,000 Extra Expense Coverage: $25,000
Rental Value Only: No
Property Options
Glass Coverage: 0 ft. Peak Season Endorsement: $0
Increased Cost: $0 Demolition Coverage: $0
Additional Insured
None
Loss Payee
None
Property Information
Risk Location Address:
15312 Eriel Ave Gardena (Los Angeles County), CA 90249-4020 Description of Operations: Parking Lot
Optional Coverage
Accounts Receiveable Amount: $0
Valuable Papers Amount: $0 Valuable Papers Deductible: 1000 Computer Data Amount: $0
Computer equipment Amount: $0 Computer Deductible: 1000
General Equipment Amoount: $0 General Equipment Rate per 100: 0.00% Inland Marine
Inside Sign Amount: $0 Outside Sign Amount: $0
Sales
Gross Sales: $0 Total Alcohol Sales: $0
Money and Securities
Money and Securites Amount: $0 Class C Safe: No
Structure
Property Description
Property Type: Normal Building Sprinkled: No Type Of Construction: Frame Year Built: 1950
Total Area: 1080 sq. ft. Occupied Area: 1080 sq. ft.
Open Sided: No Owner Occupied: No
Number of Like Structures: 1 Alarm Type: None CSP Code: 0581
Property Coverage
Building: $0 Contents: $0
Income: $0 Extra Expense Coverage: $0
Rental Value Only: No
Property Options
Glass Coverage: 0 ft. Peak Season Endorsement: $0
Increased Cost: $0 Demolition Coverage: $0
Additional Insured Manuel Mustelier, , Ca Loss Payee None Location - 15337 - 15339 Crenshaw Blvd Property Information
Risk Location Address:
15337 - 15339 Crenshaw Blvd Gardena (Los Angeles County), CA 90249-4050 Description of Operations: Insured's storage and office
Optional Coverage
Accounts Receiveable Amount: $0
Valuable Papers Amount: $0 Valuable Papers Deductible: 1000 Computer Data Amount: $0
Computer equipment Amount: $0 Computer Deductible: 1000
General Equipment Amoount: $0 General Equipment Rate per 100: 0.00% Inland Marine
Inside Sign Amount: $0 Outside Sign Amount: $0
Sales
Money and Securities
Money and Securites Amount: $0 Class C Safe: No
Structure
Property Description
Property Type: Normal Building Sprinkled: No Type Of Construction: Frame Year Built: 1949
Total Area: 1750 sq. ft. Occupied Area: 1750 sq. ft.
Open Sided: No Owner Occupied: Yes
Number of Like Structures: 1 Alarm Type: None CSP Code: 0581
Property Coverage
Building: $262,500 Contents: $20,000
Income: $0 Extra Expense Coverage: $0
Rental Value Only: No
Property Options
Glass Coverage: 0 ft. Peak Season Endorsement: $0
Increased Cost: $0 Demolition Coverage: $0
Additional Insured
None
Loss Payee
None
Property Factors
Cause of Loss: Excl Theft
Property Deductible: $1,000 Business Income Method: Monthly Limit Coinsurance Clause: 90 Monthly Income Limit: 25%
Replacement Cost: Yes Earnings Coinsurance: 100% Agreed Amount Endorsement: No Exclude Payroll: No Inflation Guard Endorsement: $0 Limit Payroll: N/A
Blanket Endorsement: No Extended Period of Indemnity: 30 days Exclude Wind & Hail: No Include Extra Expense: No
ExcludeVandalism: No Extra Expense Monthly Limit:40/80/100
Liability Factors
Liability Limit: 1000000/2000000 Fire Legal Liability: $50,000 Product Liability: Yes Advertising Liability: Yes Liability Deductible: $0 Medical Payments: $5,000 Personal Injury Liability: Yes Liquor Liability: Yes
Schedule of Classifications
Primary Classification Liability Code Premium Basis
Yes Restaurants - alcohol less than 30% receipts - table service 16910 S
No Warehouses - private 68706I A
Broker Statement
Has the risk been inspected by YOU or someone from your office? Yes
Have YOU asked every question to the insured and the insured answered them? Yes Do you think this is a good risk? Yes
Is this business currently operating? Yes Is this business still under construction? No Additional remarks to be considered when this application is reviewed:
Agent: Glenn Levine Account Executive: Erika Schmidt
I have reviewed the above application and hereby certify that all information contained therein is all true to the best of my knowledge. The Applicant should agree to implement reasonable Loss Control Requirements of the insurer when requested.
Any person who knowingly and with intent to defraud any insurance company or another person who files an application for insurance containing any materially false information, or conceals for the purpose of misleading information containing any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the person to any applicable California criminal and civil penalties.
Applicant's Signature: Date:
