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Coverage Is Provided In: <br /> +, `� Policy Number: <br /> �• Liberty Ohio Security Insurance Company BKS (21) 61 51 17 54 <br /> ` Mutual. Policy Period: <br /> INSURANCE From 07/01/2020 To 07/01/2021 <br /> 12:01 am Standard Time <br /> Commercial General Liability at Insured Mailing Location <br /> Declarations Schedule -Revised <br /> Named Insured Agent <br /> SB SUSHI INC (425) 741-3600 <br /> DBA TOKYO HOUSE SEATTLE BEST INSURANCE INC <br /> SUMMARY OF CLASSIFICATIONS - BY LOCATION <br /> 0001 500 SE Everett Mall Way Ste B100, Everett, WA 98208-8112 <br /> Insured: SB SUSHI INC <br /> CLASSIFICATION- 16910 <br /> Restaurants - With Sale of Alcoholic Beverages <br /> that are less than less than 30% of the annual <br /> receipts of the restaurants - with table service <br /> RATED/PER <br /> COVERAGE DESCRIPTION PREMIUM BASED ON- 1,000 PREMIUM <br /> Premise/Operations 436,968 Dollars Of Gross Sales 2.512 $1,098.00 <br /> Total: $1,098.00 <br /> Products/Completed Operations .122 $53.00 <br /> Minimum Premium Adjustment $57.00 <br /> Total: $110.00 <br /> SUMMARY OF OTHER COVERAGE <br /> COVERAGE DESCRIPTION PREMIUM <br /> Hired Auto Liability See Policy Forms and Endorsements List. $59.00 <br /> Non-Owned Auto Liability See Policy Forms and Endorsements List. $56.00 <br /> Restaurant Custom Protector Coverages See Policy Forms and Endorsements List $60.00 <br /> RATED/PER <br /> CLASSIFICATION - 92400 PREMIUM BASED ON- 1,000 <br /> Stop Gap - Employers Liability <br /> CG0442 - Stop Gap Employers' Liability - WA 34,344 Dollars of Payroll .174 $6.00 <br /> Minimum Premium Adjustment $72.00 <br /> To report a claim, call your Agent or 1-844-325-2467 <br /> 07/27/20 61511754 N0179270 230 NCXHPPNO INSURED COPY 002601 PAGE 12 OF 18 <br />