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A� OW CERTIFICATE OF LIABILITY INSURANCE <br />DAEIMMDDWYI <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: If the certificate holder is an ADDITIONAL INSURED, the pollcy(ies) must he endorsed. If SUBROGATION IS WAVED, subject to <br />the terms and conditions of the policy, certain policies may require 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 />E. Stacy Grass£ield <br />Lake Insurance Agency <br />PRONE (714)263-3600 FAXNu: nul:ca-voo <br />EOMAIL D RS: 9taCy@1ake1n9.COm <br />A <br />653 Sough B Street <br />INSURERS AFFORDING COVEMGE <br />NAIL A <br />Lic #0747473 <br />INSURER A. Philadelphia Ind. Ins. Co. <br />Tustin CA 92780 <br />INSURED <br />INSURERS: Philadelphia Insurance Co. <br />INSURERC: State Compensation Insurance <br />35076 <br />The Cambodian Family <br />INSURER D: <br />1626 E. 4th Street <br />INSURER E : <br />INSURERF. <br />Santa Ana CA 92701 <br />COVERAGES CERTIFICATE NUMBER:20-21 GL ❑MB 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 />RISR <br />LTR <br />TYPE OF INSURANCE <br />POLICY NUMBER <br />POLICY Err <br />IMIDDrMYI <br />POLICYEAP <br />IMMM <br />LUMS <br />A <br />X <br />COMMERCUU-01HERALLWBILY" <br />CVJMS-MADE El OCCUR <br />EACH OCCURRENCE <br />$ 1,000,000 <br />DA <br />§ 100,000 <br />MED EaP M One <br />$ 5,000 <br />X <br />Y <br />PHPx2096003 <br />3;912020 <br />.'AASIWA02 <br />PERSONAL &ADV INJURY <br />S 1,000,000 <br />GENL AGGREGATE LUATAPPLIES PER <br />GENERALAGGREGATE <br />S 3,000,000 <br />RO- <br />X POLICY1:1 JET oJs <br />PRODUCTS-COMPIOPAGG <br />S 1,000,000 <br />AnusvTbbuyftw, AN <br />5 1,000,000 <br />OTHER: <br />AUTOMOBILE <br />LABILITY <br />COMBINED SINGLE LIMIT <br />$ 1,000,000 <br />A <br />X <br />ANY AUTO f <br />ALL OWNED SCHEDULED <br />AUTOS X AUTOS <br />HIREOAUTOS X AUTOS EO <br />AUTOS <br />X <br />PHPx2086003 <br />3/9/2020 <br />3/9/20211 <br />./ <br />BODILY INJURY (per person) <br />S <br />BODILY INJURY (Per acndenn <br />S <br />PROPERTY DAMAGE <br />S <br />S 1,000,000 <br />Nm—med <br />X <br />UM8RELLAUAa <br />OCLUR <br />EACH OCCURRENCE <br />S 1,000,000 <br />AGGREGATE <br />S 11000,000 <br />IS <br />EXCESS UAB <br />CV,MS Made <br />DEO I X I RETENTIONS 10 00 <br />§ <br />[rtllaT0e2<i <br />]. Y!zOZO <br />3/n/2021 <br />C <br />ANDINGFINERSLOEIPENSA1Lr <br />AND EYPLOYERs'LI481LfTY YIN <br />ANY PROPRIETOWPARTNERIE%ECUTIVE <br />OFFICERIMEMSER EXCLUDED? <br />(Mandalo,y In NH) <br />NIA <br />906490619 <br />/ <br />✓ <br />6/30/2019 <br />6/30/2020 <br />X PER OTI4 <br />E.L. EACH ACCIDENT <br />$ 1,000,000 <br />ElDISEASE-EAEMPLOYEE <br />5 1 000,000 <br />II M. da oy under <br />EL DISEASE. POLICY LIMIT <br />S 1,000,000 <br />DESCRIPTION OF OPERATIONS Deloa <br />A <br />PZO£eE510na1 Liability <br />PHPIl2006003 <br />3/9/2020 <br />3/9/2021 <br />1,000,000 <br />Sexual or Physical Abuse <br />PRP1(2086003 <br />3/9/2020 <br />3/9/2021 <br />1,000,000 <br />DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES IACORD IDi. AWimmal RemarBs Sceedule, may Ee adachad It more space Is r Wimd) <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 />lN]:411][NL\Ei:falaaltl:�!ssnam .�. a-•1JWyswwrP <br />City of Santa Ana <br />MA . <br />Zppp <br />"Y OF THE ABOVE DESCRIBED POLICIES BE BEFORE <br />THE E%PIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN <br />Risk Management Division <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />20 Civic Center Plaza, 14-25 <br />Santa Ana, CA 92701 <br />ANC11E <br />AcEVEdo <br />AUTHORIZED REPRESENTATIVE <br />3 GLd53Cleld/STAGRA <br />lJ IOBO-ZU14 AIJVKU 6VKYVKAI 110N. All rlgnts reserved. <br />ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD <br />INS025 gouon <br />w <br />