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I
<br />Francine R. Digitally signed by Francine F.
<br />V'11 1 vllleraal
<br />area
<br />ACC)RP® CERTIFICATE OF LIABILITY INSURANCE
<br />DATE(MMMDIYYYY)
<br />1
<br />`�
<br />03126/2021
<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 Stacy Grassfield
<br />NAME:
<br />Lake Insurance Agency
<br />ONE.
<br />Ez r (it 4)263-3600 C No: (714)263-3600
<br />653 South B Street
<br />E'M Stacy@lakelns.com
<br />ADDRESS:
<br />Lic #0747473
<br />INSURER(S) AFFORDING COVERAGE
<br />NAIC 0
<br />Tustin CA 92780
<br />INSURERA: Philadelphia Ind. Ins. Co.
<br />INSURED
<br />INSURERS: Philadelphia Insurance Co.
<br />The Cambodian Family
<br />INSURER C: State Compensation Insurance
<br />35076
<br />1626 E. 4lh Street
<br />INSURER D: United States Liability
<br />NSURER E
<br />Santa Ana CA 92701
<br />INSURER F:
<br />COVERAGES CERTIFICATE NUMBER: 21-22 zGL BA PROF WC REVISION NUMBER:
<br />THIS IS TO CERTIFYTHATTHE POLICIES OF INSURANCE LISTED BELOWTPTAVE BEEN ISSUEDTOTHE INSURED NAMEDABOVE FORTHE POLICYPERIOD
<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 />AWLLSUBK
<br />INSD
<br />MD
<br />POLICY NUMBER
<br />POLICY EFF
<br />MMIDDIYYYY
<br />POLICY EXP
<br />MWDDIYYYY
<br />LIMITS
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />CLAIM&MADE FX_1 OCCUR
<br />EACH OCCURRENCE
<br />$ 1,000,000
<br />PREMISES Eaoccupence
<br />$ 100,000
<br />MED EXP(Anyone person)
<br />$ 5,000
<br />PERSONAL &ADV INJURY
<br />$ 1,000,000
<br />A
<br />Y
<br />Y
<br />PHPK2229378
<br />03/09/2021
<br />03/0912022
<br />BEVL AGGREGATE LIMITAPPLIES PER:
<br />POLICY PRO-
<br />JECT El LOC
<br />GENERAL AGGREGATE
<br />$ 3,000,000
<br />PRODUCTS - COMP/OPAGG
<br />$ 1,000,000
<br />OTHER:
<br />Abuse/Molestation Agg.
<br />$ 1,000,000
<br />AUTOMOBILE
<br />LIABILITY
<br />COMBINED SINGLE LIMIT
<br />Ea accldenl
<br />$ 1,000,000
<br />BODILY INJURY (Per person)
<br />$
<br />ANYAUTO
<br />A
<br />OWNED v SCHEDULED
<br />AUTOS ONLY /� AUTOS
<br />HIRED v NON -OWNED
<br />AUTOS ONLY /� AUTOS ONLY
<br />Y
<br />PHPK2229378
<br />03/09/2021
<br />03/09/2022
<br />BODILY INJURY Per accident
<br />( 1
<br />$
<br />X
<br />PROPERTY DAMAGE
<br />Peraccidenl
<br />$
<br />Non -owned
<br />$ 1,000,000
<br />X
<br />UMBRELLA UAB
<br />OCCUR
<br />EACH OCCURRENCE
<br />$ 1,000,000
<br />e
<br />EXCESSLILIAB
<br />CLAIMS -MADE
<br />PHUB753969
<br />03/09/2021
<br />03/09/2022
<br />AGGREGATE
<br />$ 1,000,000
<br />OED
<br />/� RETENTION $ 10,000
<br />$
<br />C
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY
<br />ANYPROPRIETORIPARTNEWEXECUTIVE ❑
<br />OFFICERIMEMBER EXCLUDED?
<br />(Mandatory In NH)
<br />DESCRIPTION under
<br />DESCRIPTION under
<br />OPERATIONS below
<br />NIA
<br />906498621
<br />06/30/2021
<br />06/30/2022
<br />v PER OTH-
<br />STATUTE ER
<br />El EACH ACCIDENT
<br />$ 1,000,000
<br />E.L. DISEASE - EA EMPLOYEE
<br />$ 1,000,000
<br />E.L. DISEASE -POLICY LIMIT
<br />1,000,000
<br />$
<br />D
<br />Professional Liability/Sexual or Physical
<br />Abuse/ LiquorrLiability
<br />PHPK2229378
<br />06122/2021
<br />05/22/2022
<br />Professional Liability
<br />Sexual or Physical Abuse
<br />$1,000,000
<br />$1,000,000ility
<br />Liquor Liability
<br />$1,000,000
<br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required)
<br />City of Santa Ana, its officers, employees, agents and representallves are Additional Insureds with respect to General Liability and Auto Liability per the
<br />attached endorsements or as required by written contract. Insurance Is Primary and Non -Contributory. 30 day cancellation notice applies unless cancelled
<br />due to non-payment -10 days.
<br />City of Santa Ana Risk Management Division
<br />20 Civic Center Plaza
<br />Santa Ana
<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 />01988-2015 ACORC
<br />ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
<br />a RiskManversentDivislon '
<br />1 *y ��L�' @. REVIEWED i& APPROVED BY:
<br />l
<br />Risk Managmment Haalyst.
<br />
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