Laserfiche WebLink
AR" CERTIFICATE OF LIABILITY INSURANCE <br />DATE (MM/DD/YYYY) <br />12/18/2020 <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 policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. <br />If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on <br />this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). <br />PRODUCER <br />CONTACT Paychex Insurance Agency Inc <br />NAME: <br />A/CONN Ext : 877-266-6850 A/C No : 585-389-7426 <br />PAYCHEX INSURANCE AGENCY, INC. <br />150 SAWGRASS DRIVE <br />ROCHESTER, NY 14620 <br />E-MAIL certs@paychex.com <br />ADDRESS: <br />INSURER(S) AFFORDING COVERAGE <br />NAIC # <br />INSURER A: STATE COMPENSATION INSURANCE FUND <br />INSURED <br />INSURER B <br />INSURER C: <br />Community Health Initiative of Orange County <br />INSURER D: <br />1505 E 17Th St Suite 121 <br />INSURER E: <br />Santa Ana, CA, 92705 <br />INSURER F : <br />COVERAGES CERTIFICATE NUMBER: 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 />INSR <br />LTR <br />TYPE OF INSURANCE <br />ADDL <br />SUBR <br />POLICY NUMBER <br />POLICY EFF <br />/Y <br />MM DDYYY <br />POLICY EXP <br />/Y MM DDYYY <br />LIMITS <br />COMMERCIAL GENERAL LIABILITY <br />EACH OCCURRENCE <br />$ <br />DAMAGE <br />CLAIMS -MADE OCCUR <br />S(RENTED <br />PREMISES Ea occurrence) <br />ccurrence)$ <br />MED EXP (Any one person) <br />$ <br />PERSONAL & ADV INJURY <br />$ <br />GEN'L <br />AGGREGATE LIMIT APPLIES PER: <br />GENERAL AGGREGATE <br />$ <br />POLICY ❑ PRO ❑ LOC <br />JECT <br />PRODUCTS - COMP/OP AGG <br />$ <br />$ <br />OTHER: <br />AUTOMOBILE <br />LIABILITY <br />COMBINED SINGLE LIMIT <br />Ea accident <br />$ <br />BODILY INJURY (Per person) <br />$ <br />ANY AUTO <br />OWNED SCHEDULED <br />AUTOS ONLY AUTOS <br />BODILY INJURY (Per accident) <br />$ <br />FIR ERTY DAMAGE <br />Per accident <br />$ <br />HIRED NON -OWNED <br />AUTOS ONLY AUTOS ONLY <br />UMBRELLA LAB <br />OCCUR <br />EACH OCCURRENCE <br />$ <br />AGGREGATE <br />$ <br />EXCESS LAB <br />CLAIMS -MADE <br />DED RETENTION $ <br />$ <br />A <br />WORKERS COMPENSATION <br />AND EMPLOYERS' LIABILITY YIN <br />ANYPROPRIETOR/PARTNER/EXECUTIVE <br />OFFICER/MEMBER EXCLUDED? E <br />(Mandatory in NH) <br />N/A <br />928909 <br />11/05/2020 <br />11/05/2021 <br />X PER OTH- <br />STATUTE ER <br />E.L. EACH ACCIDENT <br />$ 1,000,000 <br />E.L. DISEASE- EA EMPLOYEE <br />$ 1,000,000 <br />If yes, describe under <br />DESCRIPTION OF OPERATIONS below <br />E.L. DISEASE - POLICY LIMIT <br />$ 1,000,000 <br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) <br />CERTIFICATE HOLDER CANCELLATION <br />City of Santa Ana <br />Risk Management Division <br />20 Civic Center Plaza <br />Santa Ana CA 92702 <br />ACORD 25 (2016/03) <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />AUTHORIZED REPRESENTATIVE qCL <br />cF RA Management Division <br />REVIEWED & APPROVED BY: <br />@ 1988-2016 ACORD C �, , ` .. <br />The ACORD name and logo are registered marks of ACORD _ _ Risk Pjanagement Analyst <br />