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Digitally signed by Francine R.
<br />Francine R.
<br />Villareal
<br />1 /: 11 .- _ _ - I Date: 2021.09.27 14:52:52
<br />10 V I I Id I Cd I
<br />-07�194TE (MM/DD/YYYY)
<br />ACCOR o CERTIFICATE OF LIABILITY INSURANCE
<br />09/14/2021
<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 Nikki Evaniuck
<br />NAME:
<br />Poms & Associates Insurance Brokers
<br />HCNE. (800) 578-8802 q c, (818) 449-9321
<br />Ext : No):
<br />CA License #0814733
<br />E-MAIL nevaniuck@pomsassoc.com
<br />ADDRESS:
<br />INSURER(S) AFFORDING COVERAGE
<br />NAIC #
<br />5700 Canoga Ave. #400
<br />Woodland Hills CA 91367
<br />INSDRERA : Nonprofits Ins. Alliance of CA (NIAC)
<br />160
<br />INSURED
<br />INSURER B : ICW Group Insurance
<br />27847
<br />Working Wardrobes ForA New Start
<br />INSURER C :
<br />2000 E. McFadden Avenue
<br />INSURER D :
<br />Suite 100
<br />INSURER E :
<br />Santa Ana CA 92705
<br />INSURER F :
<br />COVERAGES CERTIFICATE NUMBER: 21-22 GL/AU/UMB/WC 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 />$ 500,000
<br />MED EXP (Any one person)
<br />$ 20,000
<br />PERSONAL &ADV INJURY
<br />$ 1,000,000
<br />A
<br />Y
<br />2021-4931
<br />09/17/2021
<br />09/17/2022
<br />GEN'LAGGREGATE LIMITAPPLIES PER:
<br />GENERAL AGGREGATE
<br />$ 2,000,000
<br />X POLICY ❑ PRO ❑ LOC
<br />JECT
<br />PRODUCTS-COMP/OPAGG
<br />$ 2,000,000
<br />Liquor Liability - Common
<br />$ 1,000,000
<br />OTHER:
<br />AUTOMOBILE
<br />LIABILITY
<br />5&*eNED 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 />2021-4931
<br />09/17/2021
<br />09/17/2022
<br />BODI LY I NJ U RY (Pe r accide nt)
<br />$
<br />X
<br />PROPERTY DAMAGE
<br />Per accident
<br />$
<br />HIRED NON -OWNED
<br />AUTOS ONLY AUTOS ONLY
<br />Uninsured Motorist
<br />$ 1,000,000
<br />X
<br />UMBRELLA LIAB
<br />OCCUR
<br />EACH OCCURRENCE
<br />$ 3,000,000
<br />HCLAIMS-MADE
<br />AGGREGATE
<br />$ 3,000,000
<br />A
<br />EXCESS LIAB
<br />2021-49231-UMB
<br />09/17/2021
<br />09/17/2022
<br />DED I I RETENTION $
<br />$
<br />B
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABI LI TY Y/N
<br />ANY PROPRIETOR/PARTNER/EXECUTIVE
<br />OFFICER/MEMBER EXCLUDED?
<br />(Mandatory in NH)
<br />NIA
<br />WVE5040812 03
<br />04/17/2021
<br />04/17/2022
<br />X 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 />Improper Sexual Conduct
<br />Social Service Professional Liability
<br />2021-4931
<br />09/17/2021
<br />09/17/2022
<br />General Aggregate
<br />Each Claim Limit
<br />2,000,000
<br />1,000,000
<br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
<br />RE: The City of Santa Ana Program P2E
<br />Certificate Holder, its officers, employees, agents and representatives are included as Additional Insureds per attached form. Primary non contributory
<br />applies per attached form.
<br />30 day notice of cancellation (except for 10 day notice of cancellation for non-payment)
<br />"This certificate supersedes all previously issued certificates.
<br />CERTIFICATE HOLDER CANCELLATION
<br />City of Santa Ana Risk Management Division, 4th Floor
<br />20 Civic Center Plaza
<br />Santa Ana
<br />ACORD 25 (2016/03)
<br />CA 92702
<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
<br />@ 1988-2015
<br />The ACORD name and logo are registered marks of ACORD
<br />RAManagement Division
<br />REVIEWED & APPROVED BY. -
<br />Risk Management Analyst
<br />
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