COMMUNITY HEALTH INITIATIVE OF ORANGE COUNTY

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CERTIFICATE OF LIABILITY INSURANCE DATE (MM�)DIYYYY) 0On 21/2020 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 INSURERS , AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATIONIS 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 endorsemen s . PRODUCER CONTACT NAME: PAYCHEX INSURANCE AGENCY INC/PAC PHONE (877)266-6850 (AX:, No, Ext): Fax (585)389-7894 (A/C, No): 76250881 150 SAWGRASS DRIVE E-NALADDREss: ROCHESTER NY 14620 INSURERS) AFFORDING COVERAGE NNC6 INSURER A: Hanford Accident and Indemnity Company 22357 INSURED INSURER B : COMMUNITY HEALTH INITIATIVE OF ORANGE INSURER C: COUNTY INSURER D: 1505 E 1TTH ST STE 121 INSURER E_: SANTA ANA CA 92705-8520 INSURER F : i3'itli[93i� THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED -NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE 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 TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS-MADE❑OCCUR EACH OCCURRENCE DAMAGE TO NTED MEO EXP (Any one person) PERSONAL S ADV INJURY GENLAGGREGATE LIMIT APPLIES PER: POLICY ❑PRO ❑LOC OTHER: GENERAL AGGREGATE PRODUCTS-COMPIDPAGG AUTOMOBILE LIABILITY ANYAUTO A OWNED SCHEDULED AUTOS AUTOS HIRED NON WNED AUTOS AtROS COMBINED SIN LE LIMIT BODILY INJURY (Per person) BODILY INJURY (Per acadent PROPERTY DAMAGE (Peraccident UMBRELLA DAB EXCESS LAS HOCCUR CLAIMS - MADE EACH OCCURRENCE AGGREGATE E RETENTION$ A WORKERS COMPENSATION AND EMPLOYERS'LNBILT' MY YIN PROPRIETORIPARTNER(EXECUTNE OFFICERMIEMBER EXCLUDED? (Mandatory In NH) N yes, decnbe Under DESCRIPTION OF OPERATIONS be[aw MIA 76 WEG PK2991 11/01/2019 / J 11/01/2020 X PER - OTH, ER E.L. EACH ACCIDENT $1,000,000 EL DISEASE -EA EMPLOYEE $1,000,000 El- DISEASE -POLICY LIMIT $1,OW,000 DESCRIPTION OF OPER417ONSILOCATMNS I VEHICLES (ACORD 101. Ad iftimal Rtnnift SchedUN, may Ca attached B mwe apace Is required) Those usual to the Insured's Operators. Notice of Cancellation will be provided in accordance with Form WC990394, attached to this policy. CERTIFICATE HOLDER PAAIr PI I ATInM CITY OF SANTA ANA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED RISK MANAGEMENT DIVISION / 20 CIVIC CENTER PLZ �1 BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED CCORDANCE WffH THE POLICY PROVISIONS. HORIiEO REPRESENTATIVE ISYf14at,, CQO r��ct� SANTA ANA CA 92701-4058 REVIEWED&APPRO BY RISK MANAl I Div I- LULU ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The AC and to egts[ered marks of ACORD ANgIE AcoxdO