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CERTIFICATE OF LIABILITY INSURANCE <br />DATE(MMIDDIYYYY) <br />02/21 /2020 <br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE <br />HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE <br />AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE <br />ISSUING INSURERS , AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. <br />IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATIONIS WAIVED, <br />subject to the terns and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does <br />not confer rights to the certificate holder in lieu of such endorsemen s . <br />PRODUCER <br />CONTACT NAME: <br />PAYCHEX INSURANCE AGENCY INC/PAC <br />76250881 <br />150 SAWGRASS DRIVE <br />PHONE (877)266-6850 <br />(AX:, No, Ert): <br />FAX (585) 389-7894 <br />(AIC, No): <br />ROCHESTER NY 14620 <br />E-MAIL ADDRESS: <br />INSURER(S) AFFORDING COVERAGE NAION <br />INSURER A: Hartford Accident and Indemnity Company <br />22357 <br />INSURED <br />INSURERS: <br />COMMUNITY HEALTH INITIATIVE OF ORANGE <br />INSURERC: <br />COUNTY <br />INSURER D : <br />1505 E I TTH ST STE 121 <br />INSURER E : <br />SANTA ANA CA 92705-8520 <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 <br />TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br />NSA <br />TYPE OF INSURANCE <br />ADDL <br />SUBR <br />POLICY NUMBER <br />POLICY EFF <br />POLICY EXPRGENERALAGGREGATE <br />UMffSCOMMERCIAL <br />GENERAL LIABILITY <br />ENCECLAIMS-MADE❑OCCUR <br />ENTED <br />one parson)DV <br />INJURYGEN'L <br />AGGREGATE LIMIT APPLIES PER: <br />REGATEPOLICY❑JPERO- <br />❑LOC <br />OMPIOP AGG <br />OTHER: <br />AUTOMOBILE <br />LIABILITY <br />INGLE LIMIT <br />ANY AUTO <br />RY (Per person)ALL <br />OWNED SCHEDULED <br />AUTOSHIRED <br />MINJURY <br />RY (Per a::),)AUTOS <br />NON -OWNED <br />AMAGEAUTOS <br />AUTOS <br />)UMBRELLA <br />LIARCUR <br />RRENCE <br />EXCESS LIAR <br />CLAIMS. <br />MADE <br />AGGREGATE <br />E <br />RETENTION $ <br />Y/ORNEftS COMPENSATION <br />AND EMPLOYERS' UASILRY <br />ANY YIN <br />/ <br />X <br />PEH <br />OTH- <br />E.L. EACH ACCIDENT <br />$1,000,000 <br />A <br />PROPRIETORIPARTNERIEXECUTIVE <br />OFFICERIMEMBER EXCLUDED? <br />NIA <br />76 WEG PK2991 <br />11/01/2019 <br />11/0112020 <br />EL DISEASE -EA EMPLOYEE <br />$1,000,0D0 <br />(Mandatory In NH) <br />0 M. dwcnbe under <br />EL DISEASE -POLICY LIMIT <br />$1,000,000 <br />DESCRIPTION OF OPERATIONS <br />DESCRIPTION OF OPERATIONS /LOCATIONS/VEHICLES (ACORD 101. Addhinnal Remahs Schedule, may be aLMched R mono space, Is nsepired) <br />Those usual to the Insured's Operations. Notice of Cancellation will be provided in accordance with Form WC990394, attached to this policy. <br />CERTIFICATE HOLDER CANCELLATION <br />CITY OF SANTA ANA <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED <br />RISK MANAGEMENT DIVISION / <br />BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED <br />20 CIVIC CENTER PLZ v <br />CCORDANCE WITH THE POLICY PROVISIONS. <br />Ep HORIZED REPRESENTATIVE <br />SANTA ANA CA 92701-4058 REVIEWED & APPRO <br />BY RISC MANAGEMENT DN <br />IV uwcTn Of n <br />F lup 01988-2015 ACORD CORPORATION. All rights reserved. <br />ACORD 25 (2016/03) The AC and loco arP registered marks of ACORD <br />ANfGIE A(',EVE& <br />