SB Sushi dbaTokyo House 10/14/2020

afr �\`� Coverage Is Provided In: Policy Number: • - Liberty Ohio Security Insurance Company BKS (21) 61 51 17 54 r• Mutual® Policy Period: INSURANCE From 07/01/2020 To 07/01/2021 Endorsement Period: From 07/09/2020 to 07/01/2021 Policy Change Endorsement 12:01 am Standard Time at Insured Mailing Location Named Insured Agent SB SUSHI INC (425) 741-3600 DBA TOKYO HOUSE SEATTLE BEST INSURANCE INC SUMMARY OF LOCATIONS 0001 500 SE Everett Mall Way Ste B100, Everett, WA 98208-8112 POLICY FORMS AND ENDORSEMENTS 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 13 Commercial General Liability Coverage Form - Occurrence CG 00 33 04 13 Liquor Liability Coverage Form - Occurrence CG 01 81 05 08 Washington Changes CG 01 97 12 07 Washington Changes - Employment-Related Practices Exclusion CG 04 42 11 03 Stop Gap - Employers Liability Coverage Endorsement - Washington CG 04 50 05 08 Washington Changes - Who Is An Insured CG 20 11 04 13 Additional Insured - Managers Or Lessors Of Premises *CG 20 12 04 13 Additional Insured - State Or Governmental Agency Or Subdivision Or Political Subdivision - Permits or Authorizations CG 21 06 05 14 Exclusion - Access Or Disclosure Of Confidential Or Personal Information And Data-Related Liability - With Limited Bodily Injury Exception CG 21 70 01 15 Cap on Losses from Certified Acts of Terrorism CG 21 76 01 15 Exclusion of Punitive Damages Related to a Certified Act of Terrorism *CG 24 07 01 96 Products/Completed Operations Hazard Redefined Issue Date 07/27/20 Authorized Representative To report a claim, call your Agent or 1-844-325-2467 DS 70 27 01 08 07/27/20 61511754 N0179270 230 NCXHPPNO INSURED COPY 002601 PAGE 2 OF 18