Laserfiche WebLink
A� o® CERTIFICATE OF LIABILITY INSURANCE <br />DATE(Mumorrn) <br />3/5/2020 <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: N the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. N SUBROGATION IS WAIVED, subject to <br />the terms and conditions of the policy, certain policies may reclulm an endorsement. A statement on this certificate does not confer rights to the <br />certificate holder in lieu of such endorsement(s). <br />PRODUCER <br />Lake Insurance Agency <br />653 South B Street <br />laic #0747473 <br />Tustin CA 92780 <br />CX <br />N E UCT Stacy Grassfield <br />PHONE (714)263-3600 ac rvor.". ..-`.. <br />EMAIL sta @lakeins.cOID <br />AYOREss�' <br />INSURER(SI AFFORDING COVERAGE <br />NAIL k <br />INSURERA: Philadelphia Ind. Ins. Co. <br />INSURED <br />The Cambodian Family <br />1626 E. 4th Street <br />Santa Ana CA 92701 <br />INSURERS: Philadelphia Insurance CO. <br />INSURERC:State Compensation Insurance <br />35076 <br />INSURER D: <br />INSURER E <br />INSURER F: <br />COVERAGES CERTIFICATE NLJMBER-20-21 GL Ohm 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 />LTR <br />TYPE OF INSURANCE <br />POLICY NUMBER <br />POLICY EFF <br />POLICY UP <br />LIYRS <br />A <br />X <br />COMMERCIAL GENERAL LIABILITY <br />CLAIMS -MADE [7X OCCURE <br />ENCE <br />E 1,000,000 <br />$ 100,000 <br />@e e[aM <br />E 5,000 <br />X <br />Y <br />ax Pst CP 6003 <br />3/9/2020 <br />3/9/2021 <br />ADV IWURY <br />MA� <br />1 1,000,000 <br />GENTAGGREGATE LIMITAPPLIESPER: <br />REGATE <br />E 3,000,000 <br />POLICY JET LOC <br />OMP/OPAGG <br />E 1,000,000 <br />,Ap9. <br />E 1,000,000 <br />OTHER: <br />AUTOMOSaE LABILITY j <br />COMBINED IN LE LIMIT <br />E 1,000,000 <br />E <br />A <br />ANYAUTO ✓/ <br />ALL OWNED SCHEDULED <br />AUTOS I AUTOS <br />%HIREDAUTOS NO"WNEO <br />AUTOS <br />X <br />FYPK2086003 <br />3/9/2020 <br />3/9/2021 <br />✓ <br />BODILY IWURY (Per pwmmi) <br />BODILY INJURY (PMa0ci0Ne) <br />E <br />PROPERTYDAMAGE <br />lea <br />$ <br />rpyd <br />S 1,000,000 <br />X <br />UMBRELLA LIAB <br />OCCUR <br />EACH OCCURRENCE <br />E 1,000,000 <br />AGGREGATE <br />E 1 000,000 <br />B <br />EXCESS LAB <br />CICNMS-AMDk <br />DED I % I RETENTION 10 00 <br />1 <br />E <br />PHUB708241 <br />3/9/2020 <br />1 3/9/2021 <br />C <br />WOIPER <br />COMPENSATION <br />AND KERSEMPLOYERS' <br />ANY EMPLOYERS' LIABIL IV YIN <br />ANY CERIMEETER EXCL ERIF.XECUTNE <br />OFFICERIMEMBER EXCLUDED? <br />In NH) <br />NIA <br />906A9B639 <br />/ <br />✓ <br />6/30/2019 <br />6/30/2020 <br />X <br />E.L. EACH ACCIDENT <br />E 1 000,000 <br />EL DISEASE -EA EMPLOYEE <br />E 1 000 000 <br />ff es, drory <br />a abler <br />N yes. DESCRIPTION <br />DESCRIPTION OF OPERATIONS Oekw <br />EL. DISEASE -POLICY LIMIT <br />E 1,000,000 <br />A <br />Professional Liability <br />PHPH086003 <br />3/9/2020 <br />3/9/2021 <br />1,000,000 <br />Sexual Or Physical Abuse <br />PHPI2086003 <br />3/9/2020 <br />3/9/2021 <br />1,000,000 <br />DESCRIPTION OF OPERATIONS I LOCATRNa{ I VEHICLES (ACORD 101. A001Houl Remarks Sche4ule, may M aeacheA N more apace is r"Uimo) <br />f <br />City of Santa Ana, its officers, employees, agents and representatives are Additional Insureds with <br />respect to General Liability and Auto Liability per the attached endorsements or as required by written <br />contract. Insurance is Primary and Non -Contributory - 30 day cancellation unless non -pay - 10 days.✓ <br />CFRTIFICATF HOI OFR n.. D:.L AA ---- ---- _ r.. GAT4ie.Fl I ATION <br />City of Santa Ana <br />Risk Management Division <br />202 <br />SHOULD ANY OF THE OVE BED POLICIES BE ED BEFORE <br />TITHE EXPIRATION DATE ETHER OF, NOITICE WILL BE DELIVERED IN <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />20 Civic Canter Plaza, M-25 <br />Santa Ana, CA 92701 <br />?ANqiEACEvEdo <br />A ORIZEDREPRESENTATME <br />S Grassfield/STAGRA <br />1988.2014 ACORD CORPORATION. All rights rammed. <br />ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD <br />INS025 (niQi) <br />M <br />MI <br />