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Digitally signed irson <br />yTori <br />Tori Pierson Date: 202107221615:13:13e0700' <br />/ <br />ACCOR " CERTIFICATE OF LIABILITY INSURANCE <br />FDATE'MM/DD/YYYY) <br />06104/2021 <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 Carmencita Josef <br />NAME: <br />Hays Companies Inc. <br />pHONEo (909) 243-8200 FAX (909) 243-8201 <br />NExt : C, No <br />A/C A/ <br />4200 Concours, Suite #350 <br />E-MAIL scorn c osef ha anies.com <br />ADDRESS: ) @ y P <br />INSURER(S) AFFORDING COVERAGE <br />NAIC # <br />INSURERA: Philadelphia Indemnity Ins Co <br />18058 <br />Ontario CA 91764 <br />INSURED <br />INSURER B : Insurance Company of the West <br />27847 <br />Boys & Girls Clubs of Central Orange Coast <br />INSURER C : <br />17701 Cowan, Ste. 110 <br />INSURER D : <br />INSURER E : <br />Irvine CA 92614 <br />INSURER F : <br />COVERAGES CERTIFICATE NUMBER: CL216413806 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS <br />CERTIFICATE MAYBE 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 />INSD <br />WVD <br />POLICY NUMBER <br />POLICY EFF <br />MWDD/YYYY <br />POLICY EXP <br />MM/DD/YYYY <br />LIMITS <br />X <br />COMMERCIAL GENERAL LIABILITY <br />EACH OCCURRENCE <br />$ 1,000,000 <br />CLAIMS -MADE OCCUR <br />DAMAGE TO <br />PRRETED <br />SES Ea occurrrence <br />$ 1,000,000 <br />X <br />MED EXP (Any one person) <br />$ 20,000 <br />Abuse & Molestation <br />X <br />Professional Liability <br />PERSONAL &ADV INJURY <br />$ 1,000,000 <br />A <br />Y <br />PHPK2279802 <br />06/01/2021 <br />06/01/2022 <br />GEN'LAGGREGATE LIMITAPPLIES PER: <br />GENERAL AGGREGATE <br />$ 3,000,000 <br />X POLICY ❑ PRO ❑ LOC <br />JECT <br />PRODUCTS-COMP/OP AGG <br />$ 3'000'000 <br />Employee Benefits <br />$ 1,000,000 <br />OTHER: <br />AUTOMOBILE <br />LIABILITY <br />COMBINED SINGLE LIMIT <br />Ea accident <br />$ 1,000,000 <br />X <br />BODILY INJURY (Per person) <br />$ <br />ANYAUTO <br />A <br />OWNED SCHEDULED <br />AUTOS ONLY AUTOS <br />PHPK2279802 <br />06/01/2021 <br />06/01/2022 <br />BODI LY I NJ U RY (Pe r accide nt) <br />$ <br />PROPERTY DAMAGE <br />Per accident <br />$ <br />HIRED NON -OWNED <br />AUTOS ONLY AUTOS ONLY <br />X <br />$ <br />Comp/Coll <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 LAB <br />CLAIMS -MADE <br />PHUB769704 <br />06/01/2021 <br />06/01/2022 <br />DED I X1 RETENTION $ 10,000 <br />$ <br />B <br />WORKERS COMPENSATION <br />AND EMPLOYERS' LIABI LI TY YIN <br />ANY PROPRIETOR/PARTNER/EXECUTIVE <br />OFFICER/MEMBER EXCLUDED? <br />(Mandatory in NH) <br />NIA <br />WVE 5055773 01 <br />06/01/2021 <br />06/01/2022 <br />ER /� STATUTE EORH <br />E.L. EACH ACCIDENT <br />1,000,000 <br />$ <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 />$ <br />A <br />Property -Replacement Cost <br />Special Form <br />PHPK2279802 <br />06/01/2021 <br />06/01/2022 <br />Blanket BPP <br />$921,000 <br />Deductible <br />$1,000 <br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) <br />City of Santa Ana, officers, agents, employees and volunteers are additional insured on the General Liability only per written contract, agreement or <br />memorandum of understanding. Policy is is primary and and any insurance carried by City shall be excess and non contributory. <br />30 day cancellation except 10 days for non payment of premium. <br />CERTIFICATE HOLDER CANCELLATION <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />City of Santa Ana - Risk Management Division ACCORDANCE WITH THE POLICY PROVISIONS. <br />20 Civic Center Plaza <br />AUTHORIZED REPRESENTATIVE - RideMomgmwerlMmon <br />REmEwED & APPROvED BY: <br />Santa Ana CA 92702 <br />�GIL>IILLI.Lti1.� %nxi PtertObrz <br />r <br />© 1988-2015 ACORD 1USK anagemenruencai ruse <br />ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD <br />