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MERCY-2 OP ID: SD
<br />'4�� CERTIFICATE OF LIABILITY INSURANCE
<br />Og05/17/2019TE )
<br />05/17/2019
<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 />Dufour Insurance Services, LLC
<br />5611 Littler Drive
<br />Huntington Beach, CA 92649
<br />Stephanie Dufour
<br />CONTACT
<br />NAME: Stephanie Dufour
<br />o Ext:714-369-2998 a/c No: 714-840-6357
<br />nItNEIN.,
<br />aourte ss: Stephanie@dufourinsuranee.Com
<br />INSURER(S) AFFORDING COVERAGE
<br />NAIC N
<br />INSURERA:Philadelphia Indemnity
<br />18058
<br />INSURED Mercy House Living Centers
<br />P.O. Box 1905
<br />Santa Ana, CA92702
<br />INSURER 13: Philadelphia Indemnity
<br />18058
<br />INSURERC:NOVA Casualty Company42552
<br />INSURER D: Philadelphia Indemnity
<br />18058
<br />INSURER E: Philadelphia Indemnity
<br />18058
<br />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 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 />ADDLSUBR
<br />POLICY NUMBER
<br />POLICY EFF
<br />MM/DDNYYYI
<br />POLICY EXP
<br />(MMIDD/T)rYY1
<br />LIMITS
<br />GENERAL LIABILITY
<br />EACH OCCURRENCE
<br />$ 1,000,00
<br />PREMISES Ea occurrence
<br />$ 100,00
<br />A
<br />X COMMERCIAL GENERAL LIABILITY
<br />CLAIMS -MADE aOCCUR
<br />X
<br />X
<br />PHPK1976777
<br />0510212019
<br />05102/2020
<br />MED EXP(Any one person)
<br />$ 10,00
<br />PERSONAL &ADV INJURY
<br />$ 1,000,00
<br />A
<br />X Prof. Liability
<br />PHPK1976777
<br />05/0212019
<br />05/02/2020
<br />X
<br />Sex Abuse/Miscond
<br />GENERAL AGGREGATE
<br />$ 2,000,00
<br />A
<br />PHPK1976777
<br />05/02/2019
<br />0510212020
<br />GENT AGGREGATE LIMIT APPLIES PER:
<br />PRODUCTS - COMP/OP ASS
<br />$ 2,000,00
<br />X POLICY PRO LOG
<br />Ded: $0
<br />$
<br />AUTOMOBILE
<br />LIABILITY
<br />COMBINED SINGLE LIMIT
<br />Ea accident
<br />1,DDD,DD
<br />BODILY INJURY (Per person)
<br />$
<br />A
<br />ANYAUTO
<br />X
<br />X
<br />PHPK1976777
<br />05/0212019
<br />05102/2020
<br />ALL OWNED X SCHEDULED
<br />AUTOS AUTOS
<br />HIRED AUTOS X NON -OWNED
<br />AUTOS
<br />BODILY INJURY (Per accident)
<br />$
<br />X
<br />PROPERTVDAMAGE
<br />PER ACCIDENT
<br />$ 130,00
<br />Comp/Coll Ded.
<br />$ 50
<br />X
<br />UMBRELLA LIAB
<br />X
<br />OCCUR
<br />EACH OCCURRENCE
<br />$ 5,000,00
<br />AGGREGATE
<br />$ 5,000,00
<br />B
<br />EXCESS LIAB
<br />CLAIMS -MADE
<br />X
<br />X
<br />PHUB674538
<br />0510212019
<br />05/0212020
<br />DIED I X I RETENTION$ 10000
<br />$
<br />C
<br />E
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY
<br />ANY PROPRIETORIPARTNEWEXECUrIVE YIN
<br />OFFICERIME(Mandatory In NH)EXCLUDED?
<br />dyes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />N/A
<br />X
<br />CFI-WK-10000043-03
<br />(ACCIDENT) PHLY78928850
<br />02/0812019
<br />11/21/2018
<br />0210812020
<br />1112112019
<br />X WC STATU- X TH-
<br />Y LIMRS E
<br />E.L. EACH ACCIDENT
<br />$ 1,000,00
<br />E.L. DISEASE -EA EMPLOYE
<br />$ 1,000,00
<br />E.L. DISEASE -POLICY LIMIT
<br />$ 1,000,00
<br />D
<br />Cyber Liability
<br />X
<br />X
<br />NLP3642944
<br />01/29/2019
<br />0112912020
<br />Per Occ 1,000,00
<br />E
<br />D&O/ EPLI
<br />X
<br />X
<br />PHSD1173663
<br />10/17)2018
<br />10/1712019
<br />Aggregate 1,000,00
<br />DESCRIPTION OF OPERATIONS / LOCATIONS/VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
<br />City of Santa Ana, its officers, employees, agents, volunteers and
<br />representatives are named additional insureds with respect to the operations
<br />of the named insured & this policy is primary per the attached endorsement.
<br />Workes compensation waiver of subrogation included. 10 days notice of
<br />cancellation for non-payment of premium. Ao
<br />City of Santa Ana
<br />Frank Hernandez
<br />20 Civic Center Plaza Box 1988
<br />Santa Ana, CA 92702
<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 />©1988-2010 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD
<br />
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