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QR VEHICLE OR EQUIPMENT CERTIFICATE OF INSURANCE DATE{MMlDD/YYYY) <br />Oalzsrzols <br />THlB CERTIFICATE 19 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 13ETWEP-N 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 NS form to report liability coverage <br />provided to multiple vehicles under a single policy. Use ACORD 25 forthat purpose, <br />PRODUCER David I Re B <br />David 1 Reyes, Agent r (14 527-5103 F x 7NQ Ex <br />14 5214385 <br />2840 W Lincoln Avenue �•n AIL - <br />davkl,l.r1B .bllS ✓�3latetamLcom <br />Anaheim, CA 92801 art -- <br />INSURED <br />SOSA, FELIPE <br />1517 S SYCAMORE ST <br />SANTA ANA CA 92707-2230 <br />nr--nu wrtlrq — INAIL <br />State Farm Mutual Automalrlla Insurance Company 2G178 <br />DESCRIPTION OF VEHICLE OR EQUIPMENT <br />YEAR MAKE IMANUFACTURER MODEL BODY TYPE VEHIOLI:IDENTIFICATION NUMBER <br />1999 <br />ISUZU NPR BOX JALB4B149X7015770 <br />DESCR11MON <br />SERrAL NUMBER_ <br />COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: <br />THIS IS TO CERTIFY-niATTHE POUCY(IES) OF INSURANCE LISTED nc-Lo HASMVE HEEN ISSUED TO <br />T}IE INSURED NAMEDAUOVE FOR THE POLICY <br />PERIOD($) INDICATED, NOTWiTI1STANDINO ANY REQUIREMENT, TERM OR CONDITION OF ANY <br />CONTRACTOR OTH1 R OOCUMENT WITH RESPECT TO <br />WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE ArFORDEA <br />BY THE POLICY(IES) DESCRIBED HEREIN I3/ARE SUEIJECTTO <br />ALL 'fHE TEtIl4iS, EXCLUSIONS ANO COND)TIONS OF SUCH POLICY(ICS). <br />INSR AVOL ADLICY i±Y•Tmnvr- PDLIey explRATION LTR HreuD <br />TYPE OF INSURANCE POLICY NUMBER DATC (ArAVDDFYYYV) DAT: {L6pyngiYYyY) LIMITS <br />v� <br />�1 VEHICLE I.IADI LITY COMBINEDSINOLE LiM175 1,ODODQO <br />A 350 2175-F25-75A 06125r2019 12/2512019 BODILY INJURY (Par ryemon) S <br />BODILY INJURY (Fora, a tur)q 8 <br />_ _ PROPERTY DAMAGE S <br />OENERALLIABILITY - <br />EACHOC.CURENCE <br />OCCURRENCE <br />flENERALA6eRmAYE $ <br />CLAIMS MADE <br />5 <br />INSR L96S POLICYEWEC M POLICY EXPIRATION <br />LTR AYE;¢ TYPE OF INSURANCE POLICY NUMBER DATE (MM70DIVYYY) BATE {NMNgrYYYYI LIMITS I DEDUCTIBLE <br />VEH COLLISION LOSS [I ACV AGREED AMT II LIMrr <br />-- CI L.I STATEDAMT S pEq <br />__ <br />VEH COMP VEH OTC ❑ ACV © AGREED AMT $ LIMIT <br />- © © STATED AMT S QED <br />PROPERTY ❑ ACV [I AGREED AMT <br />BASIC BROAD 6 LIMIT <br />© RC ❑ STATED AMT <br />-- SPECIAL © $ DIED <br />REMARKS (INCLUDING SPECIAL CONDITIONS / i>•THER CQyERAOB51 (Attach ACORV 101, Addhlonat Remarks achadula, It more space le mqulred) <br />DEDUCTIBLE, COMP 1000 COLL 1000 <br />ADDITIONAL INTEREST CANCELLATION t <br />sSnFppS one or the following;8HO01.ri ANY OF THE <br />At�OVE The addlllonat interest descfibad below tme been added to the II ies I10lod horeil b E4 num DD CANCELLEB <br />Po �( i Y pa Y I1EM{I ). BEFOITI_ THE LXPIRATION DATE <br />EOF, NOTICE WILL BE <br />A u sI nau I2a submigRd I0 ads Iha odUiEnnal Interest door below to the po➢typos) DELIVERP�7 IN ACCORDANCE WITH THE POLICY PROVISIONS. <br />.hv'Lb x[i5xJlumbarf➢l <br />VEHICLE IEOUIPMENTINTERBaT: LEASED FINANCED DE5CRLPYIONDPT}IEADDITIONAL INTEREST -~ <br />NAME AND ADDRESS OF ADDITIONAL INTEREST � ADDITIONAL INSURED LOSS PAYEE <br />4 <br />LIY EDER'S LOSS PAVER <br />CITY OF SANTA ANA RISK MANAGEMENT <br />LOAN I LEASC NUM <br />20 CIVIC GENTER PLAZA <br />SANTA ANA, CA 92701 o1RITJAREPRESCNTATIV6 - <br />1907 to <br />ACORD 23 (2010105) The ACORD name and logo am ronintarArt marim ..r nrnpn <br />1004361 142W7.2 01-211-2013 <br />