Laserfiche WebLink
ACPRb" VEHICLE OR EQUIPMENT CERTIFICATE OF INSURANCE, <br />DATE`MMu"m <br />L..-"' <br />bsnvaDle <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 />This form Is used to report coverages provided to a single specific vehicle or equipment, Do not use this torn to report liability coverage <br />provided to multiple vehicles under a single policy. Use ACORD 25 for that purpose, <br />PRODUCER <br />cc NAME6 Sedan Devereaux <br />5fateFarm Sarah Devereaux Bar arras <br />ac° No E.1 714.541.7260 P"x . 714.384.3802 <br />Slate Farm Agent <br />ADO IE89: sadah 7145417280.com <br />FRS° ° IOP. OF33249 <br />' 1202 W 191 St <br />Santa Ana CA 92703 <br />INSURERS AFFORDING COVERAGE <br />NAICA <br />INSURED <br />INSURER A: Stale Farm Mutual Automobile Insurance Company <br />25178 <br />EUGENIO PEREZ-MARTINEZ - <br />INSURER D: <br />1427S DOUGLAS ST <br />INSUFTER C : <br />MBVRER O; <br />SANTA ANA - CA 92704 <br />INBVRER E: <br />Ito] :[11;04 SItd11411P1a <br />YEAR MARE I MANUFACTURER MODEL <br />800Y TYPE <br />VEHICL610ENTIPICATION NUMBER <br />" 2003 HINO F52620 <br />I <br />Boz Truck <br />JHSFE2JG331S10052 <br />DfiBCRiPRON <br />VEHICL2ROUIPMENT VALUE <br />SERIALNUMOER <br />$ <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, NOTWITHSTANOING ANY REOUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO <br />WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POUCY(IES) DESCRIBED HEREIN tS/ARE SUBJECT 70 <br />. ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICY(IES), <br />INSR <br />ADGT <br />POLICYEPFECTIVE <br />POLICYEXPIRATION <br />LYR <br />NsRn <br />TYPE OF INSURANCE <br />POLICY NUMBER <br />DATE(MMMONYYI') <br />DAMjMMNOrYYY) <br />LIMITS <br />X I VEHICLE LIABILITY <br />COMBINED SINGLE LIMIT <br />S <br />A <br />5085359E11750 <br />02I2212010 <br />02J22/2019- <br />BODILY INJURY(Par Poem) <br />S 1�000,000 <br />BODILY INJURY (PM RcoAenl) <br />S 11000,000 <br />PROPERTY DAMAGE <br />S 1,000,000 <br />GENERALLIASIRY <br />EACH OCCURENCE <br />S <br />OCCURRENCE <br />GENERAL AGGREGATE <br />S <br />CLAIMS MADE <br />S <br />INSR <br />tm3e <br />POLICY EFFECTIVE <br />POLICY EXPIRATION <br />' <br />LTR <br />AYE <br />TYPE OF INSURANCE <br />POLICY NUMBER <br />DATE (AMATDfWYY) <br />DATE(MMIDOrYfYY) <br />UMJTSIOEDUCT16Le <br />ve" COLLISION LOSS <br />© ACV ❑ AGREED AMT <br />S LIMIT <br />E3 ❑ STATED ANT <br />S DEC <br />VEHCOMPJ IvaHOTO <br />El ACV ❑ AGREED ANT <br />$ LIMIT <br />V <br />❑ ❑ STATED AMT <br />$ BED <br />EQUIPMENT <br />n� <br />\rL <br />❑ ACV ❑ ADREEDAMT <br />i <br />9 LIMIT <br />BASIC BROAD <br />Z� <br />❑ RC ❑ STATEDAMT <br />SPECIAL <br />-1ra� <br />❑ <br />1 CEO <br />REMARKS (INCLUDING SPECIAL CONDITIONS/OTHER COVERAGE3)(ANaeh ACORD I9P%JdItI..IR dh.dulo. Ilm m ,..a Is q.1mid) <br />Comprehensive deductible: 100: collision deductible: 500; Uninsured Motorist protedlon 250,000/500,000 <br />ADDITIONAL INTEREST CANCELLATION <br />Select one of the following. <br />SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED <br />The 4010net lNereat dasdremd below nos baen Added to Me PMlcAies) erred herein by Rolcynumnet(s). <br />BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE <br />A mmHeesbaseeNt P,LehLNete aM'he eddNenN bdsee dw—�Fi terms m the mwies) <br />DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.IIaIM <br />vmoe <br />VEN16lEf E0U1PMENT INTEREST: LEASED I <br />FINANCED <br />DESCRIPTION OF THE ADDITIONAL INTEREST <br />X AODMONALIRSURED LOSS PAYEE <br />NAME AND ADDRESS OF ADDITIONAL INTEREST <br />CITY OF SANTA ANA <br />LENDER'S LOSS PAYER <br />20 CIVIC CENTER PLAZA <br />LOAN F LEASE NUMBER <br />SANTA ANA, CA 92701 <br />AUTHORIZED PREBE <br />--rM-T 97.2015 AC RD CORP0 7f ION: All rights reserved. <br />ACORD 23 (2016103) The ACORD name and logo are registered marks of AC0 D (/ <br />1004301 142287.4 01-262010 <br />