|
<br />Ejhjubmmz!tjhofe!cz!Gsbodjof!S/!
<br />Gsbodjof!S/!
<br />Wjmmbsfbm!
<br />Ebuf;!3133/12/17!28;25;22!
<br />Wjmmbsfbm
<br />.19(11(
<br />WISECAC-C1LKALERT
<br />DATE (MM/DD/YYYY)
<br />CERTIFICATE OF LIABILITY INSURANCE
<br />12/29/2021
<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 endorsement(s).
<br />CONTACT
<br />PRODUCER
<br />NAME:
<br />PHONEFAX
<br />Bolton Insurance Services LLC
<br />(626) 799-7000(626) 441-3233
<br />(A/C, No, Ext):(A/C, No):
<br />3475 E. Foothill Boulevard
<br />E-MAIL
<br />Suite 100
<br />ADDRESS:
<br />Pasadena, CA 91107
<br />INSURER(S) AFFORDING COVERAGENAIC #
<br />Tokio Marine Specialty Insurance Company23850
<br />INSURER A :
<br />INSURED
<br />American Healthcare Indemnity Company39152
<br />INSURER B :
<br />Philadelphia Indemnity Insurance Company18058
<br />INSURER C :
<br />Wiseplace, CA Corp. Wise Silver Center dba:
<br />1411 N. Broadway
<br />INSURER D :
<br />Santa Ana, CA 92706
<br />INSURER E :
<br />INSURER F :
<br />COVERAGESCERTIFICATE 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 />INSRADDLSUBRPOLICY EFFPOLICY EXP
<br />TYPE OF INSURANCEPOLICY NUMBERLIMITS
<br />LTRINSDWVD(MM/DD/YYYY)(MM/DD/YYYY)
<br />1,000,000
<br />A
<br />COMMERCIAL GENERAL LIABILITY
<br />X
<br />EACH OCCURRENCE$
<br />DAMAGE TO RENTED
<br />100,000
<br />CLAIMS-MADEOCCUR
<br />X
<br />PHPK23579251/1/20221/1/2023
<br />$
<br />PREMISES (Ea occurrence)
<br />X
<br />5,000
<br />MED EXP (Any one person)$
<br />1,000,000
<br />PERSONAL & ADV INJURY$
<br />2,000,000
<br />GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE$
<br />PRO-
<br />2,000,000
<br />POLICYLOC
<br />PRODUCTS - COMP/OP AGG$
<br />JECT
<br />SEXUAL PHYSICAL1,000,000
<br />OTHER:$
<br />COMBINED SINGLE LIMIT
<br />1,000,000
<br />A
<br />AUTOMOBILE LIABILITY
<br />$
<br />(Ea accident)
<br />ANY AUTO PHPK23579251/1/20221/1/2023
<br />BODILY INJURY (Per person)$
<br />OWNEDSCHEDULED
<br />AUTOS ONLYAUTOSBODILY INJURY (Per accident)$
<br />PROPERTY DAMAGE
<br />HIREDNON-OWNED
<br />XX
<br />(Per accident)$
<br />AUTOS ONLYAUTOS ONLY
<br />$
<br />1,000,000
<br />A
<br />XX
<br />UMBRELLA LIABOCCUR
<br />EACH OCCURRENCE$
<br />PHUB7959051/1/20221/1/2023
<br />1,000,000
<br />EXCESS LIABCLAIMS-MADE
<br />AGGREGATE$
<br />Personal & Adv1,000,000
<br />10,000
<br />X
<br />DEDRETENTION$
<br />$
<br />PEROTH-
<br />WORKERS COMPENSATION
<br />B
<br />X
<br />STATUTEER
<br />AND EMPLOYERS' LIABILITY
<br />Y / N
<br />SATIS03246018/15/20218/15/2022
<br />1,000,000
<br />ANY PROPRIETOR/PARTNER/EXECUTIVE
<br />E.L. EACH ACCIDENT$
<br />N / A
<br />OFFICER/MEMBER EXCLUDED?
<br />1,000,000
<br />(Mandatory in NH)
<br />E.L. DISEASE - EA EMPLOYEE$
<br />If yes, describe under
<br />1,000,000
<br />DESCRIPTION OF OPERATIONS belowE.L. DISEASE - POLICY LIMIT$
<br />Professional Liab.PHPK23579251/1/20221/1/2023
<br />Occurrence1,000,000
<br />A
<br />Employee TheftPHSD16166045/5/20216/9/2022
<br />1,000,000
<br />C
<br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
<br />GL Additional Insured applies per CG20130413 attached, only if required by written contract/agreement.
<br />Primary and Non-Contributory Wording applies per PIGL0050712 attached.
<br />Notice of Cancellation applies per IL00171198 attached,
<br />Additional Insured(s): Cify of Santa Ana, its officers, employees, agents, volunteers and representatives.
<br />RE: Operations of the named insured.
<br />CERTIFICATE HOLDERCANCELLATION
<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
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />Risk Management Division
<br />20 Civic Center Plaza, 4th floor
<br />AUTHORIZED REPRESENTATIVE
<br />Santa Ana, CA 92701
<br />ACORD 25 (2016/03)© 1988-2015 ACORD CORPORATION. All rights reserved.
<br />The ACORD name and logo are registered marks of ACORD
<br />
<br />
|