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A`C°C1IROM' VEHICLE OR EQUIPMENT CERTIFICATE OF INSURANCE, <br />OATS IMM ONYYY) <br />`L.-�' <br />6511112018 <br />THIS CERTIFICATE IS ISSUED AS AMATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS <br />CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EMEND 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 (lability coverage <br />provided to multiple vehicles under a single policy. Use ACORD 25 for that purpose. <br />PRODUCER <br />AME,C Sadah Devereaux <br />StateFarm Sadah Devereaux•Bardentos <br />aa o E ,; 714.641.7286 ae NO: 714.384.3892 <br />ft • ar, State Farm Agent <br />Eo0AlE95: StHIS 7145417200.00m - <br />vao cE <br />1202 W tat St <br />Santa Ana CA 92703 <br />INSURER(th AFFORDING COVERAGE <br />NAICX <br />INSURED <br />INSURER A: Slate Farm MUtU8[Automobile Insurance Company <br />25178 <br />EUGENIO PEREZ MARTINEZ <br />INSURE a: <br />1427 S DOUGLAS ST <br />INSURER C: <br />INSURER D: <br />SANTA ANA - CA 92704 <br />__-- <br />INSURER E: <br />101119411911111 gJ1aI1IcK01:l <br />YEAR I MAKE I MANUFACTURER <br />MODEL <br />800Y TYPE <br />VEHICLE ]CERTIFICATION NUMBER <br />" 2003 HINO <br />FE2620 <br />Box Truck <br />JHBFE2JG33i S10D52 <br />DESCRIPTON <br />VEHIOLEMOUIPMENT VALUE <br />SERIAL NUMBER <br />I <br />COVERAGES CERTIFICATE NUMBER: - REVISION NUMBER: <br />THIS IS TO CERTIFY THAT THE POLICY(IES) OF INSURANCE LISTED BELOW HASIHAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY <br />PERIODS) INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO <br />' WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POUCY(iES) DESCRIBED HEREIN ISIARE SUBJECT 70 <br />. AUL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICY(IES). <br />INSR <br />LTR <br />an <br />MSRa <br />TYPE OF INSURANCE <br />POLICY NUMBER <br />POLICYEFFECTIVE <br />DATE(MMmOM(YY) <br />POLICYEXPIIWTION <br />DATEIMMMONYYY) <br />LIMITS <br />X I VEHICLE LIABILITY <br />COMBINED SINGLE LIMIT <br />S <br />A <br />5065359E11750 <br />02/22/2018 <br />02/22/2019 <br />BODILY INJURY (Pat ao,een) <br />E 1,000,000 <br />BODILY INJURY (Pal amident) <br />S 1,000,000 <br />PROPERTY DAMAGE <br />S 11000,000 <br />GENERAL LIABiUTY <br />EACH OCCURENCE <br />5 <br />OCCURRENCE <br />GENERAL AGGREGATE <br />5 <br />CLAIMS MADE <br />5 <br />INSR <br />LTR <br />LOSE <br />AM <br />TYPE OF INSURANCE <br />POLICY NUMBER <br />POLICY EFFECTIVE <br />OATS (MMa3OANNY) <br />POLICYEXPIRATiON <br />DATE IMMIOOP Y li, <br />DMRS ICmucrBLE <br />VEH COLLISION LOSS <br />❑' ACV [I AGREED AMT <br />S LIMIT <br />❑ ❑ STATEDAMT <br />S DELI <br />VEH COMP VEH OTC <br />N <br />° <br />(] ACV ❑ ACREEa AMT <br />5 UMR <br />F� <br />[] 0 STATED AMT <br />S OEO <br />EQUIPMENT <br />BASIC BROAD <br />SPECIAL <br />�e <br />PJ� <br />F <br />�A5 <br />❑ ACV ❑ AGREED AMT <br />❑ RC ❑ STATED AMT <br />❑ <br />S LIMIT <br />7 CEO <br />Z cg\\ < <br />REMARK$(INCLUDING SPECIAL CONDITIONS I OTHER COVERAG 68) (AHQ,h ACORD I dd;donalR cAaduto, IF mom F"aa Is Awamd) <br />Comprehensive deductible: 100; collision deductible: 500; Uninsured Material protection 250,0001500,OD0 <br />ADDITIONAL INTEREST CANCELLATION <br />Select one of IhB following: <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED <br />Intl Addleenat Mtertnt dosobod INImi line bw added to the PailMlaa) Wall Fatah by polay numow(o). <br />BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE <br />n"M'e�atrat C:.nwHtdadisw V:D gd:IJrn,eline.. �t a.:.—ww eale:+wlne wnc>eeci <br />DELIVERED IN ACCORDANCE WIT' THE POLICY PROVISIONS. <br />VEHICLE I EQUIPMENT INTEREST: LEASED FINANCED <br />DESCRIPTION OF THE ADDITIONAL INTEREST <br />X ACOTRONALINSUREO LOSS PAYEE <br />NAME AND ADDRESS OF A01TRONAL INTEREST <br />CITY OF SANTA ANA <br />LENDER'S LOSS PAYEE <br />20 CIVIC CENTER PLAZA <br />LOAN I LEASE NUMBER <br />SANTA ANA, CA 92701 <br />AUINORUED PRESE ' <br />--IE-TV97.2015 AgORD CORPORAITN: IGAll rights reserved. <br />ACORD 23 (2016103) The ACORD name and logo are registered marks of ACO D 4 <br />1001381 fd]98).3 eI-E61tl14 <br />