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CERTIFICATE OF LIABILITY INSURANCE <br />DATE(MM,'DDIYYYY) <br />3/21/2018 <br />THIS CERTIFICATEIS ISSUED ASA 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(les) must have ADDITIONAL INSURED provisions or be endorsed. <br />If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this <br />certificate does not confer rights to the certificate holder In lieu of such endorsements . <br />RCONTACT <br />PAYCHEX INSURANCE AGENCY INC/PAC <br />250881 P: F:(888) 443-6112 <br />p O <br />PO BOX 015 <br />33 <br />SAN ANTONIO TX 78265 <br />NAME: <br />___ <br />PHONE at):wC,Na): (888} 443-6112 <br />EMAIL <br />ADDRESS ' <br />MSURGIDU AFFORDING COVERAGE NAICk <br />INSURER A: Hartford Ins Co of the Midwest 37478 <br />INSURED <br />COMMUNITY HEALTH INITIATIVE OF ORANGE <br />COUNTY <br />1505 E 17TH ST STE 121 <br />SANTA ANA CA 92705 <br />INSURER 8: <br />INSURERC: <br />INSURER D: <br />wsURERE. <br />1 INSURER F: <br />COVERAGES CERTIFICATE NUMBER: 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 CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS <br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE <br />TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br />INS? <br />yX <br />TYPEOFRCVURARCE <br />409L <br />IND? <br />SURR <br />t <br />POLICYNUAIRER <br />POLICYEFF <br />hININV In" <br />POLICYEY'P <br />LLArtTS <br />COMMERCIAL GENERALLIABILITY <br />EACH OCCURRENCE $ <br />CLAIMS -MADE ❑OCCUR <br />DAMAGE TO RENTED <br />PREMISES Be occurrence <br />MED Ear (Any one person) S <br />PERSONAL & ADV INJURY <br />GEN'L AGGREGATE LIMIT APPLIES PER: <br />POLICY PRO- LOC <br />JECT <br />GENERALAGGREGAm 8 <br />PRODUCTS-COMPIOPAGG S <br />OTHER: <br />AUTOMOBILE <br />LIABILITY <br />COMBINED SINGLE LIMIT <br />(En sccidsm) <br />BODILY INJURY(PO,smarn) $ <br />ANY AUTO <br />OWNED SCHEDULED <br />AUTOS ONLY AUTOS - <br />BODILY INJURY (Per a ewenq $ <br />PROPERTY DAMAGE <br />(Peraccldent) $ <br />HIREDNON-OWNED <br />AUTOS ONLY AUTOS ONLY <br />UMBRE6.LA LIAR <br />OCCUR <br />EACH OCCURRENCE - <br />EXCESS LIAR <br />CLAIMS.MADE <br />AGGREGATE 5 <br />UE AETENTaAea <br />PGR Y' HTANTE <br />E.L.EACHAOCIDENTOFFICEWMEMBER <br />SOC) <br />ANYPROPRIETORPARTNERIFDlECUTIVE YIN <br />EXCLUDED?A (MandlorylnNH) ❑ <br />NA <br />76 WEG PE2991 <br />7.1/01/2017 <br />11/01/2018 <br />E.L. DISEASE EA EMPDESCRIPTION <br />OFIf yes, describe tlOPERATIONS belowE.LDISEASE-POLICY <br />DESCRIPTION OPOPERATIONS/LOCATIONS/VEHICLES (ADDED 101, Additional Remarks Schedule, may be atlachod It more space is resulted) <br />Those usual to the Insured's Operations. <br />CERTIFICATE HOLDER CANCELLATION <br />©1088.2015 ACORD CORPORATION. All rights reserved, <br />ACORD 25 (2018/03) The ACORD name and logo are registered marks of ACORD <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED <br />BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE <br />DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. <br />CITY OF SANTA ANA <br />20 CIVIC CENTER PLZ # M-17 <br />AUTHORIZED REPRESENTATIVE <br />SANTA ANA, CA 92701 <br />©1088.2015 ACORD CORPORATION. All rights reserved, <br />ACORD 25 (2018/03) The ACORD name and logo are registered marks of ACORD <br />