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A`� or CERTIFICATE OF LIABILITY INSURANCE
<br />DA3/7/2019 )
<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 />IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
<br />the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
<br />certificate holder in lieu of such endorsement(s).
<br />PRODUCER
<br />CONTACT NAME: Stacy Grassfield
<br />PHONE (714)263-3600 FAX vwaae-Ts6a
<br />AIC, No
<br />Lake Insurance Agency
<br />653 South H Street, Suite 200
<br />E-MAIL stacy@lakeins.com
<br />ADDRESS:
<br />L1c #0747473
<br />INSURERS AFFORDING COVERAGE
<br />NAIC If
<br />INSURERA: Philadelphia Ind. Ins. Co.
<br />Tustin CA 92780
<br />INSURED
<br />INSURER B-Philadel hia Insurance Co.
<br />INSURERC:State Compensation Insurance
<br />35076
<br />The Cambodian Family
<br />INSURER o:
<br />1626 E. 4th Street
<br />NSURER E:
<br />INSURER F:
<br />Santa Ana CA 92701
<br />COVERAGES CERTIFICATE NUMBER:19-20 GL RA U1.0 WC REVISION NUMBER:
<br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
<br />INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
<br />CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
<br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
<br />INSR
<br />LTR
<br />TYPE OF INSURANCE
<br />ADDL
<br />SUER
<br />POLICY NUMBER
<br />POLICY EFF
<br />MMIDDNYYY)
<br />POLICY EXP
<br />(MMIDDIVyyyI
<br />LIMITS
<br />X
<br />CO, MERCIALGENERALLIABILITY
<br />EACH OCCURRENCE
<br />$ 1, 000,000
<br />A
<br />CLAIMS -MADE �X OCCUR
<br />DAMAGE TO RENTEO
<br />PREMISES Ea accumence
<br />$ 100,000
<br />MED EXP(Any one person)
<br />$ 5,000
<br />X
<br />PHPK1943458
<br />3/9/2019
<br />3/9/2a20
<br />PERSONAL BADV INJURY
<br />$ 1,000,000
<br />GEN-AGGREGATE LIMITAPPLIES PER:
<br />GENERALAGGREGATE
<br />$ 3,000,000
<br />PRO ❑
<br />X PRO-
<br />POLICY JECT LOG
<br />PRODUCTS - COMP/OP AGO
<br />$ 1,000,000
<br />AbuselMoleslalion Agg.
<br />IS 1,000,000
<br />OTHER:
<br />I
<br />AUTOMOBILE
<br />LIABILITY
<br />COMBINED SINGLE LIMIT
<br />Ea accident)
<br />$ 1,000,000
<br />BODILY INJURY (Perperson)
<br />$
<br />A
<br />ANVAUTO
<br />BODILY INJURY Per accident
<br />( )
<br />$
<br />ALL OWNED X SCHEDULED
<br />AUTOS AUTOS
<br />X
<br />PHPK3943458
<br />3/9/2019
<br />3/9/2020
<br />X
<br />NON-0WNED
<br />HIREDAUDOS 'Y AUTOS
<br />PROPERTY DAMAGE
<br />Per accltlem
<br />$
<br />HIndlNonawnad
<br />IS 1,000,000
<br />X
<br />UMBRELLA LIAR
<br />OCCUR
<br />EACH OCCURRENCE
<br />$ 1,000,000
<br />AGGREGATE
<br />$ 11000,000
<br />B
<br />EXCESS LIAR
<br />CLAIMS -MADE
<br />DED I X I RETENTION IS 10,000
<br />PHUB665137
<br />3/9/2019
<br />3/9/2020
<br />WORKERS COMPENSATION
<br />X PER OTH-
<br />STATUTE ER
<br />AND EMPLOYERS' LIABILITY YIN
<br />E.L. EACH ACCIDENT
<br />$ 1,000,000
<br />ANY PROPRIETORIPARTNERIEXECUTIVE
<br />C
<br />OFFICERIMEMBER EXCLUDED?
<br />N/A
<br />(Mandatory in NH)
<br />906498618
<br />6/30/2018
<br />6/30/2019
<br />E.L. DISEASE -EA EMPLOYEE
<br />$ 11000,000
<br />If yes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />E.L. DISEASE -POLICY LI MIT
<br />$ 11000,000
<br />A
<br />Professional Liability
<br />PHPK1943458
<br />3/9/2019
<br />3/9/2020
<br />1,000,000
<br />Sexual or Physical Abuse
<br />PHPK1943458
<br />3/9/2019
<br />3/9/2020
<br />11000,000
<br />DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101. Additional Remarks Schedule, may be attached If more space Is required)
<br />City of Santa Ana, Officers, Employees, Agents, Volunteers and Representatives as Additional Insured,
<br />Primary/Non-contributory, waiver of Subrogation and 30 Days Notice of Cancellation applies, as required
<br />by written contract with Named Insured.
<br />nn
<br />City of Santa Ana
<br />Officers, Employees, Agents,
<br />Volunteers and Representatives
<br />20 Civic Center Plaza, M-25
<br />Santa Ana, CA 92701
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />AUTHORIZED REPRESENTATIVE
<br />Lake—C/L/STAGRA afw-44 -,
<br />All
<br />ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
<br />INS025 (201401)
<br />
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