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DATE(MM/DD/VYYY) <br />CERTIFICATE OF LIABILITY INSU_R_ANCEU4/9v2020 <br />THIS CERTIFICATE 15 ISSUED ASAMATTEROFINFORMATION ONLVAND CONFERS NORIOHTSUPTHE ONCERTIFICATE HOLDER.THISCERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY <br />AUTHORIZED REPRESENTATIVE OR PRODUCER, ANO THE CERTIFICATE HOLDER, �I <br />AMEND, EXTEND ORALTERTHE COVERAOEAFFOR09D BYTHE POLICIES BELOW. THIS CERTIFICdTEOF INSURANCE DOES NOT CONSnTUiBA CONTRACT BETWEEN THE ISSUING INSUkEp(5), <br />IMPORTANT:1mNacortlRGale hatder t$An ADDITIONAL INSURED, ale pollry(Ms) most haVeADDDIONAL INSURED provisloneorbeendorsed. if SUBROGATION IS WAIVED, suNactto the terms and <br />condlflonsaf lhepolicy, certain papdesmnyreaulre an endonwarenLA natemeuton Udsaertlknfa doeanot confer rights retire cerORcatoholderin Ilan of such endanement(s). <br />PRODUCER ----___ �_—..—.. <br />CONTACT <br />NAME: <br />Kathy Lamm(97563414) PHONE FAX <br />2015 Rod HIII Ave 81e F201 (A/C, NO. EXT): 666416.8939 WC, Noh 866385.6146 <br />E-MAIL <br />Costa Mesa CA 92826.5958 ADoREss: klamm@farmersagent.com <br />INSURER(S)AFFORDING COVERAGE I NAICa <br />INSURED INSURERA: TNck InB6ranG6 EXChange 21709 <br />CONZALEZ, LARRY <br />/ INSURE —Farmers Insurance Exchange <br />---_-------- <br />DBA COYOTE INDUSTRIAL FABRICATION INSURERC: Mid Century Insurance Company 21887 <br />111 E STANFORD ST INSURER D: <br />SANTA ANA CA 92707 ! INSURER P. i <br />.—. COVERAGES <br />CERTIFICATE <br />COVERAGES CERTIflCA7E NUMBER: REVISION NUMBER: <br />.s_..__.___ t.._.._`_..—...___— ..—..—.._._...... TOT —HE W._—_.__ .. _-- _..—.—__—_—_ 11 <br />ot <br />t REQUIREMENT, <br />TERM <br />CONDITION <br />FANYCRANCEU51BO THER HAVE ENT I MIRESOTFIE INSURED NAME AUOVE FOR THE BE ISSUED <br />PEROR MAY ICATED.NOTWI7HSTANDING ANY <br />REQUIREMENT, TERM OR CONDITION OF M1NYCONI RACTOROTHER DOCUMENT WfnI RESPFCTTO WHICH THIS CERTIFICATE MAY 9EISSUEOOR MAY PERTAIN,THEINSURANCEAFFOROEb BYTIdE <br />POUCIES DESCRIBED I IEREIN ISSUBJECTTO ALL THE TERMS, EXCLUStONSAND CONDITIONSOF SUCH POLICIES LIMITS SHOWN MAY HAVE. BEEN REDUCED BY PAID CLAIMS <br />IN5R TYPEOFINSURANCC AODTL SUER I POLICYNUMBER POUCV EFF I- pOLICYEXP <br />LTft INS; me(MM/DD/YYYY) (MM/DD/YYYY) LIMITS / <br />' COMMRRCIAL GENERAL LIAEILfTY +^ EACH OCCURRENCE — is 1 000,00 <br />I} I _ <br />CLAIMS -MADE X OCCUR I I DAMAGETO REN fED S <br />�--J—. I—_J I PREMISES(Eaoccurmnce) 75,00 <br />B <br />....._... <br />_ ....._�... - <br />Y <br />Y <br />1606788730 04/01/2020 I 04/01/2021 PNI150NALAADVINJIIPY <br />._.,. <br />5 1,000,00 <br />I GEN'LAGGREGAITUMITAPPLIES <br />PER: <br />POLICY ) PROTECT Loc. <br />-. / .GENERAL GREM7E <br />AO <br />V I ✓"j PRODUCTS COMP/OPAO <br />IS 2QOO Q01 <br />1©F gg g <br />Ir <br />TOMO&LEUABILITY <br />iCONFINED SINGLE LIMIT ��$ <br />1000.�Oi <br />ANYAUTO <br />! <br />j 1 • ROOILYINJURY(Perperson) <br />Is <br />8 <br />owNEDqu7os SCHEDULED <br />ONLY <br />I <br />! GODLY INJURY(Paracdoem) <br />I <br />_ <br />Hums <br />t <br />�606788730 04Po1/2U20 j 0410112021 <br />HIRE <br />}� n OSONt ON-OWNCO <br />ONLY UT05 <br />ONLY <br />I <br />I i .+ PROPERTY DAMAGE <br />I$ <br />• UMBRELLALIAa - OCCUR j <br />—I _...__.._ <br />EACHOCCURkENCE $ <br />EXCESS UDE AB CLAIM&MA <br />DE I , <br />F DED RETENTIONS <br />AGGREGATE IS <br />ORKERSCOMPENSATION <br />ND EMPLOYERS'LIABILM I FL'T^ 2 I <br />ItAAp" I"���� <br />PER <br />I ( 57ATUT[ I OTHER IS <br />IVGYILYY LLI& <br />NY PNUPRIENN/PARiNCR/ YIN REVIEWED <br />1XECUTIVEOFFICER/MEMBER N/AY (j15IC MANACIEMENT IVI510N 1 <br />I <br />E L_EACII ACCIDENT -_;J' <br />EXCLUDED? (Mandatory In NH) <br />Ifye6, bauader DESCRIPTION OF _ //L1 I <br />E.L. DISEASE -EA EMPLOYEE y <br />--s----'---- <br />OpERATIONT10N5belnw � 20[ I <br />E.L UISE'A5E�POLICY LIMIT 1} <br />AcEVLda <br />DESCRIPTION OFOPERATIONS/LOCATIONS/VEHICLES (ACORD t 0 L Additimral Remark, Schedula, maybe attached if mmespace Is required) <br />Location(s): 111 E Stanford St, Santa Ana, CA 92707. THE CITY OF SANTA ANA, ITS OFFICERS, EMPLOYEES, AGENTS AND <br />VOLUNTEERS HAVE BEEN ADDED AS AN ADDITIONAL INSURED VIA A PRIMARY AND NON-CONTRIBUTORY <br />ENDORSEMENT. 30 DAY <br />NOTICE OF CANCELLATION. <br />CERTIFICATE HOLDER CANCELLATION <br />r_..._._.__..—.._.CITY`Or-SANTAArA_._. _--------._._.. _� _._.___. ____�� __ <br />SHOULDANYOFTHEABOVEDESCRIBIR UCIES RE CAN LLED DCFORETHE E%PIRATION <br />RISKMANAGEMENTDIVISION / DATE THEREOF NOTICE WRL <br />INAC(A ) C TTH THE POLICY PROVISIONS. <br />GI___ -- -- <br />20 CIVIC CENTER PLAZA 4TH FLOOR AUTHORIZED PEPRP. ATIV <br />.— _ ..__ �. — <br />-' <br />SANTAANA._ _. _. CA-92701... _. _._.. ._.: ._ <br />f/ �`� "'E y'"^•-------- J <br />ACORD 25 (2016/03) Q19 -2015 ACORD <br />CORPORATION. All Rights Reserved <br />31.1769 11 a 5 The ACORD name and logo are registered marks of ACORD <br />