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Francine R. Villareal Digitally signed by Francine R.Villareal Date: 2021.04.23 14:56:49-07'00' A�COR" CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 03/26/2021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Stacy Grassfield NAME: Lake Insurance Agency PHONE (714) 263-3600 FAX (714) 263-3600 A/C No Ext : A/C, No : 653 South B Street E-MAIL stacy@lakeins.com y� ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # Lic #0747473 Tustin CA 92780 INSURERA: Philadelphia Ind. Ins. Co. INSURED INSURER B: Philadelphia Insurance Co. The Cambodian Family INSURER C : State Compensation Insurance 35076 1626 E. 4th Street INSURER D : United States Liability INSURER E : Santa Ana CA 92701 INSURER F COVERAGES CERTIFICATE NUMBER: 21-22 zGL BA PROF WC REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BEL07J FMVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCEAUULbUbK INSD WVD POLICY NUMBER POLICY EFF MWDD/YYYY POLICY EXP MWDD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE FX OCCUR PREM SES Ea occurrDence $ 100'000 MED EXP (Any one person) $ 5,000 PERSONAL& ADV INJURY $ 1,000,000 A Y Y PHPK2229378 03/09/2021 03/09/2022 LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 3,000,000 POLICY❑ PECT ❑ LOC MOTHER PRODUCTS-COMP/OPAGG $ 1'000'000 Abuse/MolestationAgg. $ 1,000,000 : AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,000 BODILY INJURY (Per person) $ ANYAUTO A OWNED SCHEDULED AUTOS ONLY AUTOS Y PHPK2229378 03/09/2021 03/09/2022 BODILYINJURY(Peraccident) $ X PROPERTYDAMAGE Per accident $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY rx Non -owned $ 1,000,000 X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1,000,000 HCLAIMS-MADE AGGREGATE $ 1,000,000 B EXCESS LAB PHUB753959 03/09/2021 03/09/2022 DED I X1 RETENTION $ 10,000 $ C WORKERS COMPENSATION AND EMPLOYERS' LIABI LITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ (Mandatory in NH) N /A 906498620 06/30/2020 06/30/2021 ER /� STATUTE EORH E.L. EACHACCIDENT 1'000'00a $ E.L. DISEASE - EA EMPLOYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT 1,000,000 $ D Professional Liability Sexual or Physical Abuse PHPK2229378 05/22/2020 05/22/2021 $1,000,000 $1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) City of Santa Ana, its officers, employees, agents and representatives are Additional Insureds with respect to General Liability and Auto Liability per the attached endorsements or as required by written contract. Insurance is Primary and Non -Contributory. 30 day cancellation notice applies unless cancelled due to non-payment - 10 days. CERTIFICATE HOLDER CANCELLATION City of Santa Ana Risk Management Division 20 Civic Center Plaza Santa Ana CA 92701 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE © 1988-2015 ACID ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD ]ZAManagemerd Division REVIEWED & APPROVED BY.- o z P>. Vj Risk Management Analyst