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ACOK/7® VEHICLE OR EQUIPMENT CERTIFICATE OF INSURANCE GATE (NMMDNM) 1 051111201E THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. This form Is used to report coverages provided to a single speoi9c vehicle or equipment. Do not use this form to report liability coverage Provided to multiple vehicles under a single POIICy. Use ACORD 25forthat purpose. PRODUCER C ME CT Sariah Devereaux $iYiiBFdRli Sariah Devereaux-Barrientca CNH MId: 714-541.7280 aC No: 714-384ryA892 State Farm Agent E'NAIL Sariah 7145417280com 1202 W lot St PRooucER OF33249 Santa Ana CA 92703 INSUREPAS) AFFORDING COVERAGE N ICa INSURED INSURER : State Farm Mutual Automobile Insurance Company 25178 Roberto Zavala Cardenas. NSURErG: s 14132 Kerry St. INSURER C: Garden Grove Ci+2844 'L•I7[•7�9q:[[9fdvl7x.T YEAR MAKEIMANUFACTURER MOOEL BODY TYPE VEHICLE IDENTIFICATION NUMBER _1994 GMC 3500 Box Truck I iGDKC34N9R3519011 DeSONPnON VEHICLFJEOUIPMeNTVALUE SERWLNUMBER S I COVERAGES CERTIFICATE NUMBER: REVISION NUMRFR! THIS IS TO CERTIFY THAT THE POLICY(IES) OF INSURANCE LISTED BELOW HASIHAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD(S) INOICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICYQES) DESCRIBED HEREIN ISfARE SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICY(IES). "SR LTR ADO'L menu TYPE OF INSURANCE POLICY NUMBER POUCYEFFECBVE DATE(MMIGOIYYYY) POLICY EXPIRATION OATE(MWODNYYYI LIMITS X VEHICLE LIABILITY COMBINED SINGLE LIMIT S A 7957781E-72-758 12/9212017 -121t2l2tl18 BODILY INJURY(Perpormn) S 1,000,000 BODILY INJURY (ParauNem) S 1,000,000 ' PROPERTY DAMAGE $ 1xio,o00 GENERAL LIABILITY EACH OCCURENCE S OCCURRENCE GENERALAGOREDATa S CLAIMS MADE to INSR LTR was AYEE TYPe OFINSURANCE POLICY NUMBER POUCYEFFECTIVE DATE(MMIDDIYYYYI POLICY EXPIRATION DATE(MWODW" LIMITSIDEOUCTIBLE VEH COLLISION LOSS ©ACV ❑AGREEDAMT $ UMIr ❑ ❑ STATEDAMT S DED VEHCOMP VEH OTC + Q ACV ❑ AGREEDAMT S LIMIT �.` ❑ ❑ STATED AMT S DED EQUIPMENT ---�nq 4 ❑ ACV ❑ AGREEO AMT BASIC BROAD SPECIAL V�\V �* �' f� ,` ❑ RC ❑ STATED AMY Cl It LIMIT E DED REMgRK3(INCLVOINO SPECIAL CONOmONS t OTHER COVERAGES)~h tOt,Ad k6 Remarks SoheOate, It man a pan is required) CDmprehensNe deduc0ble: 100; collision deductible: 500; Uninsured MI: it 250,0001500,000 ADDITIONAL INTEREST CANCEL I ATION Select one of the following: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED The addvnN lotemat 4burlbed Wow has bean added to the pdicy(ies) Ivted homin by potoy%mber(s). BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL SE A seat bee bean sabmillod to add the aabuonai interest dmdbad Move v the polirylvst a. DELIVERED IN ACCORDANCE WITH TH€PID CYPROVISIONE. VEHICLEI EQUIPMENT INTEREST: LEASED FINANCED DESGRtPTNJN OR IHEADDRNJNAL WTEREST X ADDDIONALINSURED LOSS PAYEE NAME AND ADDRESS OF AODITWNAL INTEREST CITY OF SANTA ANA LENDER'S 6436 PAYEE 20 CIVIC CENTER PLAZA LOAN I LEASE NUMBER J— SANTA ANA, CA 02701 AUTHDRIZEDR RESENTA 7• COR g is reserved. ACORD 23 (20103) The ACORD name and logo are registered marks of ACORD 9004161 102987.1 OtB&a116