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<br />ACORa CERTIFICATE OF LIABILITY INSURANCE
<br />DATE(MM/DDNYYY)
<br />06/04/2021
<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 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(les) 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 />LUNTACT Carmencita Josef
<br />NAME:
<br />Hays Companies Inc.
<br />PHON(909) 243-8200 ^x 909 )243-8201
<br />(
<br />ME.,1AIC No
<br />C:
<br />4200 Concour3, Suite #350
<br />E-MAIL cJosefQhayscompanles.com
<br />ADDRESS:
<br />INSURERS) AFFORDING COVERAGE
<br />NAIC #
<br />Ontario CA 91764
<br />INSURERA: Philadelphia Indemnity Ins Co
<br />18058
<br />INSURED
<br />INSURER B: Insurance Company of the West
<br />27847
<br />Boys & Girls Clubs of Central Orange Coast
<br />INSURER C:
<br />17701 Cowan, Ste. 110
<br />INSURER D:
<br />INSURER E:
<br />Irvine CA 92614
<br />INSURER F:
<br />:ERTIFICATE NUMBER: UI-216413806
<br />THIS IS TO CERTIFYTHAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVE FOR THE POLICY PERIOD
<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 />TR
<br />TYPE OF INSURANCE
<br />INSD
<br />WVD
<br />POLICY NUMBER
<br />POLICYEFF
<br />MMIDDIYYYYI
<br />YEXP
<br />IMMIDDNYYYI
<br />LIMITS
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />CLAIMS -MADE [X OCCUR
<br />EACH OCCURRENCE
<br />$ 1,000,000
<br />PREMISES Ea occurrence
<br />$ 1,000,000
<br />X
<br />MED EXP(Any one person)
<br />$ 20,000
<br />Abuse & Molestation
<br />X1
<br />Professional Liability
<br />PERSONAL &ADV INJURY
<br />$ 1,0005000
<br />A
<br />Y
<br />PHPK2279909
<br />06101/2021
<br />06/01/2022
<br />GEN'L AGGREGATE LI MIT APPLI ES PER:
<br />X POLICY PRO-
<br />JECT LOC
<br />GENERAL AGGREGATE
<br />$ 3,0005060
<br />PRODUCTS - COMP/OP AGG
<br />$ 3,0005000
<br />OTHER:
<br />Employee Benefits
<br />$ 1,000,000
<br />AUTOMOBILE
<br />LIABILITY
<br />COMBINED SINGLE LIMIT
<br />Ea accldent
<br />$ 1,000,000
<br />X
<br />BODILY INJURY (Per person)
<br />$
<br />ANYAUTO
<br />A
<br />OWNED SCHEDULED
<br />AUTOS ONLY AUTOS
<br />PHPK2279802
<br />06/01/2021
<br />06101/2022
<br />BODILY INJURY (Per accldent )
<br />$
<br />HIRED NON-0WNED
<br />AUTOS ONLY AUTOS ONLY
<br />PROPERTYDAM4GE
<br />Peramident
<br />$
<br />X
<br />$
<br />Comp/Coll
<br />X
<br />UMBRELLA LIAB
<br />X
<br />OCCUR
<br />EACH OCCURRENCE
<br />$ 5,000,000
<br />A
<br />EXCESS LIAB
<br />CLAIMS -MADE
<br />PHUB769704
<br />06/01/2021
<br />06/0112022
<br />AGGREGATE
<br />$ 5,000,000
<br />DED
<br />I X1 RETENTION $ 10,000
<br />B
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY
<br />ANY PROPRIETCRIPARTNEWEXECUTIVE YIN
<br />OFFICEWMEMBER EXCLUDED? ❑N
<br />(Mandatory In NH)
<br />?ryes, describe antler
<br />DESCRIPTION OF OPERATIONS below
<br />NIA
<br />WVE 505577301
<br />06/01/2021
<br />06/01/2022
<br />PER OTH-
<br />X STATUTE ER
<br />E.L. 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 />A
<br />Property -Replacement Cost
<br />Special Form
<br />PHPK2279802
<br />06/01/2021
<br />06/0112022
<br />Blanket BPP
<br />$921,000
<br />Deductible
<br />$15000
<br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES IACORD 101, Additional Remarks Schedule, may be attached If more space Is rec ul red)
<br />City of Santa Ana, officers, agents, employees and volunteers are additional insured on the General Liability only per written contract, agreement or
<br />memorandum of understanding. Policy Is Is primary and and any insurance carried by City shall be excess and non contributory.
<br />30 day cancellation except 10 days for non payment of premium.
<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 - Risk Management Division ACCORDANCE WITH THE POLICY PROVISIONS.
<br />20 Civic Center Plaza
<br />AUTHORIZED REPRESENTATIVE ,t „�, RlakbiawgmudlDMdmt
<br />Santa Ana CA 92702 �. A� 9 j'r prcW
<br />n i7RR.gn14ArnPn `rsiskM19anaoenant ClMulNde ;T
<br />ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD V
<br />
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