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Digitally signed by Fmndne R.
<br />Francine R. Villareal Villareal
<br />MERCY-2 11: 216101 J b1.3:§fJ11 '
<br />,a►coRo CERTIFICATE OF LIABILITY INSURANCE
<br />TE
<br />FDA05/10/2021Y)
<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 be endorsed. If SUBROGATION IS WAIVED, 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 />Dufour Insurance Services, LLC
<br />5611 Littler Drive
<br />CONTACT
<br />NAME: Stephanie Dufour
<br />A/c"r o Ext :714-369-2998 (A//C, No): 714-840-6357
<br />Huntington Beach, CA 92649
<br />Stephanie Dufour
<br />E-MAIL
<br />hanie dufourinsurance.com
<br />ADDRESS: Stephanie@dufourinsurance.com
<br />INSURER(S) AFFORDING COVERAGE
<br />NAIC #
<br />INSURERA:Philadelphia Indemnity
<br />18058
<br />INSURED Mercy House Living Centers
<br />INSURERB: NOVA Casualty Company
<br />42552
<br />P.O. Box 1905
<br />Santa Ana, CA 92702
<br />INsuRERc:Axis Insurance Company
<br />013034
<br />INSURER D : Tokio Marine Specialty Ins
<br />INSURER E :
<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 />DDL
<br />INSR
<br />UBR
<br />WVD
<br />POLICY NUMBER
<br />POLICY EFF
<br />MM/DD/YYYY
<br />POLICY EXP
<br />MM/DD/YYYY
<br />LIMITS
<br />GENERAL LIABILITY
<br />EACH OCCURRENCE
<br />$ 11000,000
<br />A
<br />X COMMERCIAL GENERAL LIABILITY
<br />X
<br />X
<br />PHPK2266697
<br />05/02/2021
<br />05/02/2022
<br />DAMAGE TO RENTED
<br />PREMISES Ea occurrence
<br />$ 100 000
<br />CLAIMS -MADE � OCCUR
<br />MED EXP (Any one person)
<br />$ 10,000
<br />A
<br />X Prof. Liability
<br />PHPK2266697
<br />05/02/2021
<br />05/02/2022
<br />PERSONAL & ADV INJURY
<br />$ 1,000,000
<br />A
<br />X
<br />Sex Abuse/Miscond
<br />PHPK2266697
<br />05/02/2021
<br />05/02/2022
<br />GENERAL AGGREGATE
<br />$ 2,000,000
<br />GEN'LAGGREGATE LIMIT APPLIES PER :
<br />PRODUCTS - COMP/OP AGG
<br />$ 2,000,000
<br />X POLICY PRO LOC
<br />JECT
<br />Ded.- $0
<br />$
<br />AUTOMOBILE LIABILITY
<br />COMBINED SINGLE LIMIT
<br />Ea accident
<br />1000000
<br />$ , ,
<br />BODILY INJURY (Per person)
<br />$
<br />A
<br />ANY AUTO
<br />X
<br />X
<br />PHPK2266697
<br />05/02/2021
<br />05/02/2022
<br />X ALLOWNED X SCHEDULED
<br />AUTOS AUTOS
<br />BODILY INJURY (Per accident)
<br />$
<br />X HIRED AUTOS X NON -OWNED
<br />AUTOS
<br />PROPERTY DAMAGE
<br />PER ACCIDENT)
<br />$
<br />Comp/Coll Ded.
<br />$ 50
<br />X
<br />UMBRELLA LIAB
<br />X
<br />OCCUR
<br />EACH OCCURRENCE
<br />$ 5,000,000
<br />AGGREGATE
<br />$ 5,000,000
<br />A
<br />EXCESS LIAB
<br />CLAIMS -MADE
<br />X
<br />X
<br />PHUB765396
<br />05/02/2021
<br />05/02/2022
<br />DED X RETENTION $ 10000
<br />$
<br />B
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY
<br />ANY PROPRIETOR/PARTNER/EXECUTIVE Y/"
<br />X
<br />CF1-WK-10000043-05
<br />02/08/2021
<br />02/08/2022
<br />X WC STATU- OTH-
<br />TORY LIMITS ER
<br />E.L. EACH ACCIDENT
<br />$ 1,000,000
<br />OFFICER/MEMBER EXCLUDED? ❑
<br />(Mandatory in NH)
<br />N / A
<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 />C
<br />Cyber Liability
<br />X
<br />X
<br />RPS AXIS P-077342121
<br />01/29/2021
<br />01/29/2022
<br />Per Occ 1,000,000
<br />A
<br />D&O/ EPLI
<br />X
<br />X
<br />PHSD1592213
<br />12/17/2020
<br />12/17/2021
<br />Aggregate 1,000,000
<br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
<br />City of Santa Ana, its officers, employees, agents, volunteers and
<br />representatives are named additional insureds with respect to the operations
<br />of the named insured & this policy is primary per the attached endorsement.
<br />Workes compensation waiver of subrogation included. 30 days notice of
<br />cancellation for non-payment of premium.
<br />CERTIFICATE HOLDER CANCELLATION
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />City of Santa Ana
<br />y
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL
<br />BE DELIVERED IN
<br />Risk Management Division
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />20 Civic Center Plaza, 4th Fir
<br />Santa Ana, CA 92702
<br />AUTHORIZED REPRESENTATIVE
<br />Risk Mar,agernentDiBY
<br />REVIEWED & APPROVm BY.-
<br />©1988-2010 ACORD CO
<br />WM44441
<br />ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD
<br />`'
<br />Risk Management Analyst
<br />
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