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ACOR& VEHICLE OR EQUIPMENT CERTIFICATE OF INSURANCE DATE fmmmorYYY) 02/13/2019 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 specific vehicle or equipment. Do not use this form to report liability coverage provided to multiple vehicles under a single policy. Use ACORD 25 for that purpose. PRODUCER °°"T^°T Sariah Devereaux State&)IM Sarah Devereaux-Barrientos ac°Nro Ex: 714-541-7280 FA C. ND; 714-3843092 • State Farm Agent • • . 9 E-MAIL ADDRE s: SaLh3@714541728O.com cu0sr0orein ID :aLh3@74145417280.com 1202 W 1 st St Santa Ana CA 92703 INSURERS AFFORDING COVERAGE NAICX INSURED INSURER A: State Farm Mutual Automobile Insurance Company 25178 Roberto Zavala Cardenas & Cristina Zavala Reyes INSURER B: DBA Galaxy Party Rentals INSURER C : 14132 Kerry St INSURER D ; GARDEN GROVE CA 9284$ INSURER E: DESCRIPTION OF VEHICLE OR EQUIPMENT YEAR MAKE I MANUFACTURER MODEL BODYTYPE VEHICLE IDENTIFICATION NUMBER 1994 1 GM( 3500 Box Truck 1GDKC34N9RJ519011 DESCRIPTION VEHICLEJEQUIPMENT VALUE SERIAL NUMBER COVERAGES CERTIFICATE NUMBER' RFVICITIN NIIMRFR- THIS IS TO CERTIFY THAT THE POLICY(IES) OF INSURANCE LISTED BELOW HAS/HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD(S) INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICY(IES) DESCRIBED HEREIN IS/ARE SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICY(IES). INSR LTR ADDL INSRD TYPE OF INSURANCE POLICYNUMBER POLICY EFFECTIVE DATE(MMIDDNYYY) PODCYEXPMATKIN DATE(MLVDbNYYY) LIMITS X I VEHICLE LABILITY COMBINED SINGLE LIMIT $ 1,000,000 BODILY INJURY (Per pomm) $ A 1957791-F12.75B 02/13/2019 12/12/2019 BODILY INJURY (Pm accident) $ PROPERTY DAMAGE $ GENERALLMSILITY EACH OCCURENCE $ OCCURRENCE GENERAL AGGREGATE $ CLAIMS MADE Med Pay $ 5,000 INSR LTR Lose A TYPE OF INSURANCE POLICY NUMBER POLICYEFFECTNE DATE(MMIDOIYYYY) POLICYEXPIIIATNON DATE (MI DD/YYY'n LIMITS I DEDUCTIBLE VEH COLLISION LOSS - ❑` ACV ❑AGREED AMY $ LIMIT ❑ ❑ STATED AMT f DEC, VEH COMP VIER OTC ❑' ACV ❑AGREED AMT $ LIMIT ❑ ❑ STATED AMT f DED EQUIPMENT ❑ ACV [I AGREED AMT BASIC R BROAD SPECIAL ❑ RC ❑STATED AMT ❑ $ LIMIT f DED REMARKS (INCLUDING SPECIAL CONDRION$ I OTHER COVERAGES) (Atfaah ACORD 101, Additional Remarks Salwdui. if men apace is mquln ) 1 1'�� Comprehensive deductible: 100; Collision deductible: 500; Uninsured motorist protection: 250,000/500,000 :A\Ik ADDITIONAL INTEREST CANCELLATION 1�— "I Ilia' Select ors of the following: SHOULD ANY OF THE ABOVE DESCR FEQL-)CI E'CANCELLED Theetlditionel interestdmaibed bebr has bean added mow pdig(ias)Ilsled herein by pdicy numbar(s). BEFORE THE EXPIRATION DATE ILL BE A has Deer) submiMul m and the additimal interest descabad below to Me policy(m) DELIVERED IN ACCORDANCE P 11'PROVISIONS. Munt m n —e VEHICLE I EQUIPMENT INTEREST: I ILEASED I I FINANCED DESCRIPTION OF THEADD LINTERGa t-' X ADDITIONALINSURED RLOSSPAYEE NAME AND ADDRESS OF ADDITIONAL INTEREST LENDER'S LOSS PAYEE CITY OF SANTA ANA LOAN /LEASE NUMBER 20 CIVIC CENTER PLAZA SANTA ANA CA 92701 AurHORIZED REPRESENTA 01997-201S ACORD CORPO,R74TION. All rights reserved. ACORD 23 (2016/03) The ACORD name and logo are registered marks of ACORD 1004361 14nfr`3 01-2&2016