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A ?!?El VEHICLE OR EQUIPMENT CERTIFICATE OF INSURANCE <br />DATE IMMIDDNYYY' <br />�1r..� <br />05111@018 <br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS <br />CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES <br />BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED <br />REPRESENTATIVE OR PRODUCER; AND THE CERTIFICATE HOLDER. <br />This form is used to report coverages provided to a single specific vehicle or equipment. Do not use this form to report liability coverage <br />provided to multiple vehicles under a single policy. Use ACORD 25 for that purpose. <br />PRODUCER <br />NAME: Sarah Devereaux <br />StateFarm Sarah Devereaux -ea Boron <br />a°N4 ,t. 714-541-7280 PaAxc N714-384.3892 <br />State Farm Agent <br />A. <br />E MAI <br />ADDRESS:. sarah@7145417280.00m <br />1202 W 1st St <br />PR oCERCL1m OF33249 <br />Santa Ana CA 92703 <br />INSURER E AFFORDING COVERAGE <br />NAIL r <br />INSURED <br />INSURER A; Stale Farm Mutual ADiGmoblle Insurance Company <br />25178 <br />EUGENIO PEREZ MARTINEZ <br />INSURER B: <br />1427 S DOUGLAS ST <br />INSURER C <br />NSURER D; <br />SANTA ANA CA 92704 <br />INSURER E: <br />YEAR MORE I MANUFACTURER <br />MODEL <br />BUOY TYPE <br />VEHICLE IDENTIFICATION NUMBER <br />- 2003 HIND <br />FE2620 <br />Box Truck <br />JHBFE2JG331S10052 <br />DESCRIPTION <br />VENICLEMCUIPMENT VALUE <br />SERIAL NUMBER <br />S <br />THIS IS TO CERTIFY THAT THE POLICY(IES) OF INSURANCE LISTED BELOW HAS/HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY <br />PERIOD($) INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM -OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO <br />WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICY(IES) DESCRIBED HEREIN IS/ARE SUBJECT TO <br />. ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICY(IES). <br />INSR <br />LTR <br />AODI <br />MrpD <br />TYPE OF INSURANCE <br />POLICY NUMBER <br />POLICY EFFECTIVE <br />DATE(MMIDD/YYYYI <br />POLICY EXPIRATION <br />DAM(MMIDUIYYYY) <br />LIMITS <br />X I VEHICLE LIABILITY <br />COMBINED SINGLE LIMIT <br />$ <br />A <br />5065359E1175D <br />02/22/2018 <br />02/2212019 <br />BODILY INJURY (Pet trench) <br />5 1,000,000 <br />BODILY INJURY (Perecddent) <br />5 1,000,p00 <br />PROPERTY DAMAGE <br />5 11000,000 <br />' <br />GENERAL LIABILITY <br />EACH OCCURENCE <br />S <br />OCCUR0.ENCE <br />GENERAL AGGREGATE <br />S <br />CLAIMS MADE <br />S <br />INSR <br />LTR <br />Loss <br />PAYE <br />TYPE OF INSURANCE <br />POLICY NUMBER <br />POLICY EFFECTNB <br />DAM(MMNORYYY) <br />POLICY EXPIRATION <br />DATE(101"DIYYYY) <br />LIMITS I DEDUCTIBLE <br />VEH COLLISION LOSS <br />[]i ACV ❑AGREED AMT <br />S LIMIT <br />❑ ❑ STATED AMT <br />ItDED <br />VEH COMP VEH OTC <br />V <br />ACV ❑ AGREED AMT <br />E LIMIT <br />❑ ❑ STATEOAMT <br />S DED <br />EQUIPMENT <br />BASIC BROAD <br />SPECIAL <br />� <br />y� ^/ <br />:A <br />�� <br />❑ ACV [IAGREEDAMT <br />0 RC ❑ STATED AMT <br />LIMIT <br />S CEO <br />GNa <br />REMARKS (INCLUDING SPECIAL CONDITIONS I OTHER COVERAGES) (Ahach ACORD I Mid on.IR chnftlo. Il more 1P.00 is ropulred) - <br />Comprehensive deductible: 100; collision deductible: 500; Uninsured Motorist protection 250,000/500,000 <br />Select one of the following: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED <br />no eddlllonelinteresl dogviued blow Iran been added to the policy(ies) listed herein by policy number(s). BE FORE TH E EXPIRATION DATE TH EREOF, NOTICE WILL BE <br />Are� <br />tedurns hos been rubrWhihi to Bold the edtitlonol interest dsaaibed hlcw inthe ehicl(ies) DELIVERED INACCORDANCE WITH THE POLICY PROVISIONS. <br />lisNareM by Aeiic numbertel. <br />VEHICLE I EQUIPMENT INTEREST I ILEASEO I (FINANCED <br />NAME AND ADDRESS OF ADDITIONAL INTEREST <br />CITY OF SANTA ANA <br />20 CIVIC CENTER PLAZA <br />SANTA ANA, CA 92701 <br />X ADDITIONAL INSURED LOSS PAYEE <br />LENDER'S LOSB PAYEE <br />LOAN (LEASE NUMBER <br />ACORD 23 (2016/03) The ACORO name and logo are registered marks of ACOIrD v <br />1004361 142987.3 0145-2016 <br />