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Francine R. Villareal vlliareai - <br />Date: 2021.08.10 15:32:36-07'00' <br />R w CERTIFICATE OF LIABILITY INSURANCE <br />F DATIa(wDINYYYtry <br />Q7130/2021 <br />TH15 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 pollcy(les) must have ADDITIONAL INSURED provisions or be endorsed, <br />If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, cortalp policies may require an endorsement, A statement on <br />this certificate does not confer rights to the certificate holder in lieu of auch ondorsoment s . <br />PRODUCER <br />CONTAOF Alexandra <br />FB ROY JEFFERSON, AGENT <br />FxA/oNrO 714-283 5336 _.._ 1 /ot 714.283-5941 <br />116 $ CHAPARRAL COURT, SUITE 250 <br />AJ) REIIIIalexandra@royjefferson net <br />ANAHEIM HILLS, CA 92808 <br />_ INSURER@tAFFORDINe OOVERAQE NAICq <br />NsuRa A: State Farm Mutual Automobile Insurance Company <br />25178 <br />INsukaD <br />NSURER e: stale Farm Gonaral Insurance Company <br />25151 <br />AIMTDLLC <br />wsuaERc: ��— _..._.__--_ _ <br />_ <br />751 WEIR CANYON RD STE 167-158 <br />INSURERD; — �RW �— <br />ANAHEIM,CA928G8 <br />INSURER <br />INSURER F: <br />COVERAGES CERTIFICATE NUMBER: REVISION NUMBCR <br />THIS IS TO CERTIFY THAT THE POLICIES OP INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ASOVE 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 REDUCEDBY PAID CLAIMS. <br />INSR— -�- - bUNii P05. , F <br />LTRTYPE DP INSURANCE POLICY NUMBER MN/pp; - IDDIYVYY LIMITS <br />COMMERCIAL GENERAL LIABILITY <br />EACH OCCURRENCE <br />8 2,000,000 <br />CLAIMS4MADE X OCCUR <br />'tiAMAGE TO RENTELT—_ <br />'2,000,000 <br />,RE�II�Ey_(E oxurranG <br />$ tl <br />_�+ <br />MED EXP (AY ona�e766f�) <br />$ 5,000 <br />B <br />Y <br />Y <br />92-CX-M179-0 <br />02126/2021 <br />02126/2022 <br />PERSONAL&ADViNJukY <br />$ 2,000 000 <br />GEHL <br />GENERAL AGGREGATE <br />$ 4000,000 <br />AGGREGATE LIMIT APPLIES PER: <br />POLICY 0 JECR LOC <br />FROCUOTS.. comp/Bp AGG <br />_ <br />$ 2,000.660 <br />$ <br />OTHER: <br />AUTOMOBILE <br />UABIL17Y <br />Y <br />Y <br />5156448-COB-75 <br />09/08/2020 <br />09/08/2021 <br />¢ BINED SINGLELIMIT <br />q 1,000,000 <br />- <br />ANY AUTO <br />"" <br />6403716-B28.75 <br />08/2812020 <br />08/28/2021 <br />BOOli.v1NJURY(Perpereoni <br />s <br />A <br />OWNBq SCHEDULED <br />AUTOS ONLY AU'ros <br />GORILY INJURV (Aoraedl cni) <br />__ <br />$ <br />HIRED <br />NO -OWNED <br />56471S1-A16.75 <br />01/16/2021 <br />01/1612022 <br />p pEizrYDAMAG�-- <br />y <br />_ <br />oNLv <br />ld <br />UMBRELLA UPS OCCUR <br />_ <br />EACH OCCURRENCE <br />EXCESS LIAB ._ CLAIMS -MADE <br />AOGREGATE <br />BEDRETENTION,; <br />WORKERS COMPENSATION <br />ER <br />AND EMPLOYERS'LIABILITY YIN <br />T E .,.0- <br />I3 <br />ANY PROPRIETONIPARTNER/EXECUTIVE <br />OFFICERIMEMBEREXCLUDED7 <br />NIA <br />Y <br />$2-GO-F2004 <br />02/28/2021 <br />02/28/2022 <br />EL. EACH ACCIDENT <br />$ 1,000,000 <br />(Mmomtory in NH) <br />R.L.D18EASP-EA EMPLOYEE <br />S 1,000.000 <br />It 9peg desonoo under <br />DES IPTION OFOPERATI glow <br />I <br />"-""'•""'—"'—^---- <br />E.L.DISEASP•POLICY LIMIT <br />— <br />1,000,000 <br />DESCRIPTION OF OPERATIONS LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule,: may be motional It more space Is received) <br />30 DAY NOTICE OF CANCELLATION, EXCEPT FOR 10 DAYS NON PAYMENT OF PREMIUM WILL BE PROVIDED <br />Additional Insured:The City of Santa Ana, its ofHcars, officials, employees, and volunteers <br />City of Santa Ana <br />Risk Management Divislon. <br />20 Civic Center Plaza <br />Santa Ana, CA 92702 <br />SHOULD ANY OF I <br />THE EXPIRATION <br />ACCORDANCE IND <br />ACORD 25 (2016103) THo ACORD name and logo are registered: marks oYACORD <br />CANCELLED BEFORE <br />BE DELIVERED IN <br />Jr <br />I° REVIEWED&APPROVED BY:. <br />I"E' Rbk ManagementAlnelyst <br />