|
Francine R. Digitally signed by Francine R.
<br />Villareal
<br />Villareal Date: 2021.06.1614-15:20-07'00'
<br />A�URD® CERTIFICATE OF LIABILITY INSURANCE
<br />DATE (MMIDDIYYYY)
<br />06/08/2021
<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(les) must have ADDITIONAL INSURED provisions or be endorsed.
<br />If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
<br />this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
<br />PRODUCER
<br />StateFarm TERRY BRADSHAW, AGENT LIC. #01380831
<br />SANTIAGO BLVD., SMITE 207
<br />Ww.
<br />VILLA PARK, CA 92861
<br />CONTACT KAREN VASQUEZ
<br />NAME:
<br />PHONE 714-637-4120 FAX No : 714-637-4260
<br />IAJC. No. ExtIm INC,17871
<br />E-MAIL
<br />ADDRESS: KAREN@TERRYBRADSHAW.ORG
<br />INSURERS AFFORDING COVERAGE
<br />NAIL
<br />INSURER A: State Farm General Insurance Company
<br />25151
<br />INSURED
<br />HENNESSEY & HENNESSEY, LLC.
<br />17602 17TH STREET, SUITE 102-246
<br />TUSTIN, CA 92780
<br />INSURERS: State Farm Mutual Automobile insurance Company
<br />25178
<br />INSURERC:
<br />INSURERD:
<br />INSURER E:
<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 />MSR
<br />LTR
<br />TYPE OFINSURANCE
<br />ADDL
<br />SUER
<br />POLICY NUMBER
<br />POLICY EFF
<br />MMIDDIYYYY
<br />POLICY EXP
<br />MMIDDIYYYY
<br />LIMITS
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />EACH OCCURRENCE
<br />$ 1 ,000,000
<br />CLAIMS -MADE X OCCUR
<br />DAMAGE TO RENTED
<br />PREMISES Ea occurrence
<br />$ 300,400
<br />MEU EXP (Any one person)
<br />$ 5,000
<br />A
<br />Y
<br />Y
<br />92-CZ-W382-6
<br />05/16/2021
<br />05/16/2022
<br />PERSONAL & ADV INJURY
<br />$ 11000,000
<br />GEN'L
<br />AGGREGATE LIMIT APPLIES PER:
<br />GENERAL AGGREGATE
<br />$ 2,000,000
<br />X
<br />POLICY PRO ❑ LOC
<br />JECT
<br />PRODUCTS - COMPIOP AGO
<br />$ 2,000,000
<br />OTHER:
<br />AUTOMOBILE LIABILITY
<br />Y
<br />Y
<br />4717092-E19-75G
<br />05/19/2021
<br />11/19/2022
<br />COMBINED SINGLE LIMIT
<br />Ea accident
<br />1,000,000
<br />BODILY INJURY (Per person)
<br />$
<br />ANY AUTO
<br />BODILY INJURY (Peraccident)
<br />$
<br />B
<br />OWNED SCHEDULED
<br />AUTOS ONLY AUTOS
<br />HIRED NON -OWNED
<br />X AUTOS ONLY X AUTOS ONLY
<br />PROPERTY DAMAGE
<br />frier accident)
<br />$
<br />$
<br />X
<br />UMBRELLA LIAB X
<br />OCCUR
<br />EACH OCCURRENCE
<br />$ 2,000,000
<br />A
<br />EXCESS LIAR
<br />CLAIMS -MADE
<br />N
<br />N
<br />92-CZ-W386-5
<br />05/15/2021
<br />05/15/2022
<br />AGGREGATE
<br />$ 2,000,000
<br />DED RETENTIONS
<br />$
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY YIN
<br />ANY PROPRIETORlPARTNERlE%ECUTIVE ❑
<br />OFFICEPJMEMBER EXCLUDED?
<br />(Mandatory In NH)
<br />N ! A
<br />PEROTH-
<br />STATUTE I ER
<br />E.L. EACH ACCIDENT
<br />$
<br />E.L. DISEASE - EA EMPLOYE
<br />$
<br />E.L. DISEASE - POLICY LIM17
<br />$
<br />It yes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
<br />City of Santa Ana, officers, agents, employees, and volunteers are named as additionally insured on this policy pursuant to written contract, agreement, or
<br />memorandum of understanding. Such insurance as is afforded by this policy shall be primary, and any insurance carried by City shall be excess and
<br />noncontributory
<br />Certificate of Insurance shall provide thirty (30) day prior written notice of cancellation
<br />CERTIFICATE HOLDER CANCELLATION
<br />CITY OF SANTA ANA
<br />RISK MANAGEMENT DIVISION
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />THE EXPIRATION DATE T EREOF, NOTICE WILL BE DELIVERED IN
<br />ACCORDANCE WITH THE Cy PROVISION) Q /
<br />AUTHORIZED
<br />20 CIVIC CENTER PLAZA Completed by an authorised State F
<br />SANTA ANA, CA 92702 is required, please contact a State „.oa,N RiakMvwgcrr a&DMsian
<br />% REVIEWED & APPROVED BY:
<br />©1988-2015 ACORD C F,4� P, (!J&,."J
<br />ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD "®` Risk Management Analyst
<br />
|