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ACOR& VEHICLE OR EQUIPMENT CERTIFICATE OF INSURANCE <br />DAM(MMIDDIYYY)n <br />03/03/2020 <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 />This form is used to report coverages provided to a single specific vehicle or equipment. Do not use this form to report liability coverage <br />provided to multiple vehicles under a single policy. Use ACORD 25 for that purpose. <br />PRODUCER <br />CONTACT Sariah Devereaux <br />NAME: <br />StateFarm Sariah Devereaux-Barienlos <br />AIc No Eat: 714-541-7280 Ac No, 714-384-3892 <br />�. Stale Farm Agent <br />ADMAIL <br />DRE sariah@7145417280.com <br />CCuosiomERID, OF33249 <br />1202 W 1st St <br />INSURE S) AFFORDING COVERAGE <br />NAIC0 <br />Santa Ana CA 92703 <br />INSURED <br />INSURER A: State Farm Mutual Automobile Insurance Company <br />25178 <br />ZAVALA CARDENAS, ROBERTO & ZAVALA REYES / <br />INSURER B: <br />INSURER C <br />CRISTINA DBA COSMOS EVENT RENTALS ✓ <br />1773 W LINCOLN AVE STE S <br />INSURER D: <br />ANAHEIM CA 92801 <br />INSURER E: <br />DESCRIPTION OF VEHICLE OR EQUIPMENT <br />YEAR <br />MAKE I MANUFACTURER <br />MODEL <br />BODY TYPE <br />VEHICLE IDENTIFICATION NUMBER <br />1994 <br />1 GMC <br />3500 <br />BOX <br />1GDKC34N9RJ519011 <br />DESCRIPTION <br />VEHIDLEIEQUIPMENT VALUE <br />SERIAL NUMBER <br />$ I <br />COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: <br />THIS IS TO CERTIFY THAT THE POUCY(IES) OF INSURANCE LISTED BELOW HAS/HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY <br />PERIOD(S) INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO <br />WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POUCY(IES) DESCRIBED HEREIN IS/ARE SUBJECT TO <br />ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICY(IES). <br />INSR <br />LTR <br />AIKr <br />IN9Rb <br />TYPE OF INSURANCE <br />POLICY NUMBER <br />POLICY EFFECTIVE <br />DATE(MMIDONYYY) <br />POLICY EXPIRATION <br />DATE(MMIDONYYY) <br />UNITS <br />A <br />Y <br />X I VEHICLE LIABILITY <br />195 7791-F12-75C <br />02/13/2020 <br />02/13/2021 <br />COMBINED$INGLE LIMIT <br />$ 1,000,O00 <br />BODILY INJURY (Perpereeti <br />S <br />BODILY INJURY (Per ecdCerrt) <br />$ <br />PROPERTY DAMAGE <br />$ <br />GENERAL LABILITY <br />OCCURRENCE <br />CLAIMS MADE <br />EACH OCCURENCE <br />$ <br />GENERAL AGGREGATE <br />S <br />MEDICAL PAYMENT <br />s 5.000 <br />INSR <br />LTR <br />Loss <br />PAYEq <br />TYPE OF INSURANCE <br />POLICY NUMBER <br />POLICYEPFECTNE <br />DATE (MMODrY1'Y) <br />POLICYEXPIRATR)N <br />DATE (MMIDDArl YYI <br />LIMITS I DEDUCTIBLE <br />VEH COLLISION LOSS <br />❑' ACV ❑' AGREED AMT <br />❑ ❑ STATEDAMT <br />S LIMIT <br />$ DED <br />VEH COMP VEH OTC <br />QACV ❑AGREED AMT <br />❑ ❑ STATED AMT <br />S LIMIT <br />$ DIED <br />EQUIPMENT <br />BASIC BROAD <br />SPECIAL <br />❑ ACV ❑ AGREED AMT <br />D ANT <br />cREVIEWED & A <br />DEDT <br />f ROVED <br />y IS ANAC4EM <br />P <br />NT IVISION <br />REMARKS (INCLUDING SPECIAL CONDITIONS I OTHER COVERAGESI (AeaM ACORD 101, AtltlRlomi Remarks SchedUN, X mom space N mciulletl) <br />Uninsured motorist protection: 250,000 / 500,000 ; Deductibles: Comprehensive $1001 Collision $500 A <br />ADDITIONAL INTEREST CANCELLATION <br />Select one of the following: <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED <br />)( Thdn e adtiSorW interest desbeolow behas been tooled th to e pd"(Kie)listsd neten by policy motbernn <br />BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE <br />A mi,u St "S bean ¢ bmined to ado the additional Interest described below to me polry(iea) <br />I <br />DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. <br />listed hemin by ooliPv <br />VEHICLE I EQUIPMENT INTEREST: LEASED <br />FINANCED <br />DESCRIPTION OF THE ADDITIONAL INTEREST <br />X ADDITIONAL INSURED PAYEE <br />NAME AND ADDRESS OF ADDITIONAL INTEREST <br />RLOSS <br />LENDER'S LOSS PAYEE <br />City of Santa Ana <br />LOAN I LEASE NUMBER <br />20 Civic Center Plaza <br />Santa Ana CA 92701 <br />AUTHqNED RgPRESEN TIVE <br />llJttl_.Q. B <br />0 1997-201frACORD CORPORATION. All rights reserved. <br />ACORD 23 (2016/03) The ACORD name and logo are registered marks of ACORD <br />10M361 142997.3 01-262016 <br />