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ACOKO� VEHICLE OR EQUIPMENT CERTIFICATE OF INSURANCE DADomvYr 051111201 20188 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. This form is used to report coverages provided to a single specific vehicle or equipment. Do not use this form to report liability coverage provided to multiple vehicles under a single policy. Use ACORD 25 for that purpose. PRODUCER CONTACT NAME: Sedan Devereaux $tdiBF3/I/I Sadah Devereaux-Barrientoa 00NNa: 714541-7280 FAX Net! 714-3843892 owState Farm Agent E-mAIL a sariah 7145497280.com 1202 W 1st St PR0%mEERR ID . OF33249 Santa Ana CA 92703 INSURERIS AFFORDING COVERAGE NAIC0 INSURED INSURERA: State Farm Mutual Automobile Insurance Company 25178 Roberto Zavala Cardenas INSURER 8: 14132 Kerry St. INSURER c - NSURER D: Garden Grove CA 92844 INsuR E DON OF VEHICLE OR EOt YEAR MAKE/MANUFACTURER MODEL BODY TYPE VEHICLE IDENTIFICATION NUMBER 1994 GMC 3500 Box Truck 1GDKC34N9RJ519011 DESCRIPTION VEHICLEIEQUIPMENT VALUE SERIAL NUMBER COVERAGES CERTIFICATE NUMRFR' ocvl¢rAM MnMnco. THIS IS TO CERTIFY THATTHE POLICY(IES)OF INSURANCE LISTED BELOW HASIHAVE BEEN ISSUED TO THE INSURED NAMEDABOVE FOR THE POLICY PERIODS) INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICY(IES) DESCRIBED HEREIN ISIARE SUBJECTTO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICY(IES). INSR LTR ADIYL we. TYPEOFINSURANCE POLICY NUMBER POLICYEFFECTIVE DATE(MMIDp IYYYY) POUCYEXPIRATION PATE (MM1VDPIYYYY) LIMITS X VEHICLE UABILRY COMBINED SINGLE LIMIT $ A 1957791 F-12-758 12/12/2017 12/12/2078 BODILY INJURY (Par person) $ 1,000,00D BODILY INJURY (PerawitlaM) $ 1,000,000 PROPERTY DAMAGE S 11000,000 GENERAL LIABILITY EACH OCCURENCE S OCCURRENCE GENERALAGGREGATE S CLAIMS MADE $ INSR LTR Lase PAYEE TYPEOPINSURANCE POUCYNUMBER POLICY EFFECTIVE DATE(MM)DUIYYYYI POLICY EXPIRATION DATE(MMIDDIYYYY) LIMITS I DEDUCTIBLE VEH COLLISION LOSS ❑' ACV ❑AGREED AMT $ LIMIT ❑ ❑ STATED AMT It DIED VEH COMP VEH OTC o QACV El AGREED AMT $ LIMIT ❑ El STATED AMT $ DED EQUIPMENT BASIC R BROAD SPECIAL n n��G ❑ ACV ❑ AGREED AMT ❑ RC ❑ STATED AMT ❑ f LIMIT $ DED REMARKS (INCLUDING SPECIAL CONDITIONS I OTHER COVERAGES)(ANach RD 101911 Remarks Schedule, if spae. is referred) Comprehensive deductible: 100: collision deductible: 500; Uninsured MotBdst protection 250,0001500,000 AUUI I ZONAL IN I EKES I CANCELLATION Select one ofthe following: The addhronel interest described below he. been added to the policy(ies) listed herein by parity number(.). SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE A reaa�ast has been submitted to add the additional interest described bebw to the policy(ins) Ilatetl herel b o m ra. DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. VEHICLE I EOUIPMENT INTEREST: LEASED FINANCE° DESCRIPTION OF THE ADDITIONAL INTEREST X ADDITIONAL INSURED LOSS PAYEE NAME AND ADDRESS OF ADDITIONAL INTEREST CITY OF SANTA ANA LENDER'S LOES PAYEE 20 CIVIC CENTER PLAZA LOAN I LEASE NUMBER SANTA ANA, CA 92701 AUTHORIZEDR RESENTA 7 COR I rig is reserved. ACORD 23 (2016103) The ACORD name and logo are registered marks of ACORD 10C1361 1425487.3 01-26.2016