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Digitally signed by Francine R.
<br />Francine R. Villareal Villareal
<br />nara�m t n� m 1 �nFna ��mro
<br />CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)
<br />V 7/l/2022 6/29/2021
<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 endorsements ,
<br />PRODUCER Lockton Insurance Brokers, LLC
<br />777 S. Figueroa Street, 52nd Fl.
<br />CA License #0F15767
<br />Los Angeles CA 90017
<br />NAME:
<br />PHONE pAX
<br />teuc No
<br />E-MAIL
<br />ADDRESS:
<br />INSURER(S) AFFORDING COVERAGE
<br />NAIC #
<br />(213) 689-0065
<br />INSURER A: Philadelphia Indemnit Insurance Co.
<br />18058
<br />INSURED Community SeniorServ, Inc.
<br />1495634 Dba Meals on Wheels Orange County ty
<br />1200 N. Knollwood Cit.
<br />Anaheim CA 92801
<br />INSURER B : Redwood Fire and Casualty Insurance Co
<br />11673
<br />INSURER C
<br />INSURER D :
<br />INSURER E :
<br />INSURER F :
<br />crniconr_cc �nr.,ro�nr n�n�•1�.n.�•�. .. ,_._.__.
<br />--------------•••--•-• a.l-r,v 11 RGY101VIV IYUIVIDIMM; AAAAAAA
<br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE
<br />POLICY PERIOD
<br />INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH
<br />THIS
<br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO
<br />ALL THE TERMS,
<br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
<br />ILTR TYPE OF INSURANCE L SUBR POLICY NUMBER POLICY EFF POLICY EXP
<br />MM/DD MM/DD LIMITS
<br />A
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />CLAIMS -MADE OCCUR
<br />Y
<br />N
<br />PHPK2291894
<br />7/1/2021
<br />7/l/2022
<br />EACH OCCURRENCE
<br />$ 1,000 000
<br />DAM DE-TO-IRMITM
<br />PREMISESlEa occurrence)
<br />$_ 1 00O 000
<br />MED EXP (Any one person)
<br />$ 20,000
<br />PERSONAL & ADV INJURY
<br />$ 1 000,000
<br />LIMIT APPLIES PER:
<br />❑ PE�
<br />GENERAL AGGREGATE
<br />$ 3000000
<br />GEN'LAGGREGATE
<br />PRODUCTS - COMP/OP AGG
<br />$ 30000 000
<br />X
<br />POLICY LOC
<br />OTHER:
<br />$
<br />A
<br />AUTOMOBILE
<br />LIABILITY
<br />N
<br />N
<br />PHPK2291894
<br />7/1/2021
<br />7/1/2022
<br />COMBINED SINGLE LIMIT
<br />Ea accident
<br />$ 1 OOO OOO
<br />X
<br />ANY AUTO
<br />..,..-......1................,...._....._............
<br />BODILY INJURY (Per person)
<br />. _..._..f._..,._._a_.....-,..w_._...._..,.,..,...,.
<br />$ j{3IXXXXX
<br />OWNED SCHEDULED
<br />AUTOS ONLY AUTOS
<br />BODILY INJURY (Per accident)
<br />$ XXXXXXX
<br />HIRED NON -OWNED
<br />AUTOS ONLYLY
<br />AUTOS ONLY AUTOSXXXXXXX
<br />PROPERTY DAMAGE
<br />Per eccident�„•_,„,„,,,_.,,,,_.
<br />....._,..,.....
<br />$
<br />...µµ-.,.,...�_w_
<br />Com .Ded.
<br />1,000
<br />A
<br />X
<br />UMBRELLA LIAB
<br />X
<br />OCCUR
<br />N
<br />N
<br />PHUB773736
<br />7/1/2021
<br />7/1/2022
<br />EACH OCCURRENCE
<br />$10000000
<br />EXCESS LIAB
<br />CLAIMS -MADE
<br />AGGREGATE
<br />$ 10,000 000
<br />DED I X I RETENTION $ 10,000
<br />$ XXXXXXX
<br />B
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY YIN
<br />ECUTNEFN
<br />�
<br />N
<br />COWC247800
<br />7/1/2021
<br />7/1/2022
<br />_
<br />X STATUTE I I ERH
<br />E.L. EACH ACCIDENT
<br />$ 12000,000
<br />OFFICEBER EXCLUDED?
<br />a (Mandtory In If yes, describe aundnder
<br />NIA
<br />E.L. DISEASE -EA EMPLOYEE
<br />$ 1,000,000
<br />E.L. DISEASE - POLICY LIMIT $ 1 000 000
<br />DESCRIPTION OF OPERATIONS below
<br />A
<br />A
<br />Prof. Liab.
<br />Sexual/Physical Abuse or
<br />Y
<br />N
<br />PHPK2291894 (Prof. Liab.)
<br />7/1/2021
<br />7/1/2022
<br />$1,000,000; Agg. limit: $3,000,000
<br />Molestation
<br />PHPK2291894
<br />7/1/2021
<br />7/1/2022
<br />$1,000 000 Occ./$2,000,000 Agg
<br />DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required)
<br />The City of Santa Ana, its officers, employees, agents, representatives and volunteers are an Additional Insured to the extent provided by the policy language or
<br />endorsement issued or approved by the insurance carrier. Insurance provided to Additional Insured(s) is primary and non-contributory as per the attached
<br />endorsements or policy language.
<br />/'. Cf1TIr1I. 1, T,� „w, ,•.,�e�
<br />15476274 The City of Santa Ana, Risk Management SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />20 Civic Center Plaza THE EXPIRA71ON DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />Santa Ana CA 92701 ACCORDANCE WITH THE POLICY PROVISIONS.
<br />AUTHORIZED REPR
<br />,,,. 1 Nsk R1sItAl�nagc+rlarLD[viefan
<br />,��/ REvEWED&APPROVED BY:
<br />o 88-201 c D c I,� .,
<br />ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD Risk Management Analyst
<br />
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