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I lanullc n. venal cal •' <br />Dale: 2021.06.21 1]:29:09-0700' <br />A4CC)J? �® CERTIFICATE OF LIABILITY INSURANCE <br />DA06/10/2021ry) <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(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 endorsements . <br />PRODUCER <br />StateFafTfi Sariah Devereaux-Barrientos, Agent <br />1417 S Broadway <br />CONTACT <br />NAME: <br />PHON E. 714_541-7280 IFC. No: <br />ADDRE SS:: sadahlQ7145417280.com <br />Santa Ana, CA 92707 <br />INSURERS AFFORDING COVERAGE <br />NAIC N <br />INSURER A: State Farm Fire and Casualty Company <br />25143 <br />INSURED <br />INSURERS: <br />Mental Inc' <br />INSURER C : <br />12664 Chapman Ave <br /> <br /> <br /> <br /> F: <br />COVERAGES CERTIFICATE NUMBER: RFVIRION NUMRPR- <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 />INSR <br />TYPE OF INSURANCE <br />ADDL <br />SUBR <br />POLICY NUMBER <br />POLICY EFF <br />fmmmoIYYYYl <br />POLICY UP <br />I rMNUDDfYYY)nLIMITS <br />X <br />COMMERCIAL GENERAL LIABILITY <br />EACH OCCURRENCE <br />$ 1,000,000 <br />CLAIMS-MADEI OCCUR <br />PREMISES occuur ante <br />$ 300,000 <br />MED EXP (Any one person) <br />$ 5,000 <br />PERSONAL B ADV INJURY <br />$ 1,000,000 <br />A <br />Y <br />Y <br />92-EK-V825-4 <br />05/16/2021 <br />05/16/2022 <br />GEN'L <br />X <br />AGGREGATE LIMIT APPLIES PER: <br />POLICY JECT[71 LOC <br />GENERALAGGREGATE <br />$ 2,000,000 <br />PRODUCTS-COMP/OP ADD <br />$ 4,000,000 <br />BUSINESS PROPER <br />$ 11,700 <br />OTHER: <br />AUTOMOBILE <br />LIABILITY <br />COMBINED SINGLE LIMIT <br />a acciden <br />$ <br />BODILY INJURY (Per person) <br />$ <br />ANY AUTO <br />OWNED SCHEDULED <br />AUTOS ONLY AUTOS <br />BODILY INJURY ParamHent <br />( ) <br />$ <br />HIRED NON -OWNED <br />AUTOS ONLY AUTOS ONLY <br />PROPERTYDAMAGE <br />Per accident <br />$ <br />8 <br />UMBRELLA Luke <br />OCCUR <br />EACH OCCURRENCE <br />$ <br />AGGREGATE <br />$ <br />EXCESS LIAR <br />CLAIMS -MADE <br />DEO I I RETENTIONS <br />$ <br />WORKERS COMPENSATION <br />PER OTH- <br />AND EMPLOYERS' LIABILITY YIN <br />STATUTE BR <br />EL. EACH ACCIDENT <br />$ <br />ANY PROPRIETOR/PARTNER/EXECUTIVE <br />OFFICER/MEMBER EXCLUDED? ❑ <br />NIA <br />EL. DISEASE - EA EMPLOYE <br />$ <br />(Mandatory in NH) <br />If yes, describe under <br />DESCRIPTION OF OPERATIONS be. <br />EL. DISEASE -POLICY LIMIT <br />$ <br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached N more apace Is required) <br />The City of Santa Ana, its officers, officials, employees, and volunteers are to be covered as additional insureds on the CGL policy with respect to liability <br />arising out of work or operations performed by or on behalf of the Contractor including materials, parts, or equipment furnished in Connection with such work or <br />operations. <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 />The City of Santa Ana Risk Management Division <br />20 Civic Center Plaza AUTHORIZED REPRESENTATIVE <br />Santa Ana, CA 92702 <br />ACORD 25 (2016/03) <br />PM <br />01988-2015 ACORD <br />The ACORD name and logo are registered marks of ACORD <br />IuRe mmagemer¢ urI n m. <br />REVIEWED&APPROV®Sr. <br />V:P WAI <br />RBk Management Analyst <br />