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XW Lr <br />�..---� CERTIFICATE OF LIABILITY INSURANCE <br />DATE(MM/DD/YYYY) <br />12/20/2021 <br />THISCERTIFICATE IS ISSUED ASA MATTEROF INFORMATION ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOTAFFIRMATIVELYOR NEGATIVELY <br />AMEND, EXTEND ORALTER THE COVERAGE AFFORDED BYTHE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), <br />AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. <br />IMPORTANT: If the certificate holder isan ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisionsor be endorsed. If SUBROGATION IS WAIVED, subject to the terms and <br />conditions of thepollgO certain policies mayrequireanendorsement Astatementonthis certificatedoesnotconferrightstothecertificateholderinlieu ofsuchendorsement(s), <br />PRODUCER <br />CONTACT <br />NAME- James Lundin <br />LUNDIN JAMES(0713365) <br />PHONE <br />FAX <br />700 E 9TH AVE #105 <br />(A/C, NO, E)T): 303-433-4542 <br />(A/C, NO): 866-614-1373 <br />E-MAIL <br />DENVER CO 80203 <br />ADDRESS- jlundin@farmersagent.com <br />INSURER(S) AFFORDING COVERAGE <br />NAIC # <br />INSURED <br />INSURERA: Truck Insurance Exchange <br />21709 <br />INSURERB: Farmers Insurance Exchange <br />21652 <br />HEALTHY OUTCOMES, INC. <br />7897E 24TH AVE <br />INSURERC: Mid Century Insurance Company <br />21687 <br />INSURERD: Fire Insurance Exchange <br />21660 <br />INSURERE: <br />DENVER CO 80238-2451 <br />INSURERF. <br />COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: <br />THIS IS TO CERTIFYTHATTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAME ABOVE FORTHE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY <br />REQUIREMENT, TERM OR CONDITION OFANY CONTRACTOR OTHER DOCUMENT W ITH RESPECTTO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE <br />POLICIES DESCRIBED HEREIN IS SUBJECTTO ALLTHE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br />INSR <br />LTR <br />TYPEOFINSURANCE <br />ADDTL <br />INSD <br />SUBR <br />WVO <br />POLICYNUMBER <br />POLICY EFF <br />(MM/DD/YYYY) <br />POUCYEXP <br />(MM/DD/YYYY) <br />LIMITS <br />COMMERCIAL GENERAL LIABILITY <br />EACH OCCURRENCE <br />$ <br />CLAIMS MADE F1 OCCUR <br />DAMAGE TO RENTED <br />PREMISES (Ea Occurrence) <br />$ <br />MED EXP (Any one person) <br />$ <br />PERSONAL& ADV INJURY <br />$ <br />GENT AGGREGATE UMITAPPLIES PER: <br />GENERALAGGREGATE <br />$ <br />POLICY ❑ PROJECT ❑ LOC <br />PRODUCTS-COMP/OPAGG <br />$ <br />$ <br />OTHER: <br />AUTOMOBILE LIABILITY <br />COMBINED SINGLE LIMIT <br />(Ea accident) <br />$ <br />BODILY INJURY (Per person) <br />$ <br />ANYAUTO <br />BODILY INJURY (Per accident) <br />$ <br />OWNEDAUTOS SCHEDULED <br />ONLY AUTOS <br />HIREDAUTOS NON -OWNED <br />ONLY AUTOSONLY <br />PROPERTY DAMAGE <br />(Per accident) <br />$ <br />UMBRELLALIAB <br />OCCUR <br />EACH OCCURRENCE <br />$ <br />EXCESS LIAB <br />CLAIMS -MADE <br />AGGREGATE <br />$ <br />DED I I RETENTION $ <br />$ <br />WORKERS COMPENSATION <br />AND EMPLOYERS'LIABILI Y <br />X1 <br />PER <br />STATUTE <br />OTHER <br />$ <br />E.L. EACH ACCIDENT <br />$ 1,000,000 <br />D <br />ANY PROPRIETOR/PARTNER/ Y/N <br />EXECUTIVEOFFICER/MEMBER <br />EXCLUDED? (Mandatory in NH) Y <br />N/A <br />Y <br />04176360 <br />01/17/2022 <br />01/17/2023 <br />E.L. DISEASE -EA EMPLOYEE 1,000,000 <br />E.L. DISEASE -POLICY LIMIT <br />$ 1,000,000 <br />Ifyes, describe under DESCRIPTION OF <br />OPERATIONS below <br />DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) <br />ertificate holder is listed as Additional insured on the named Insured's general liability policy. <br />aiver of Subrogation applies in favor of the certificate holder on the workers compensation policy. The consultant hereby grant to Grantee a waiver of any right <br />o subrogation which any insurer of said consultant may aquire against City by virtue of the payment of any loss under such insurance. Consultant agrees to <br />btain any endorsement that may be necessary to affect this waiver of subrogation, but this provision applies regardless of whether or not the City has received a <br />CERTIFICATE HOLDER CANCELLATION <br />City of ants Ana SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CA BE E PIRATION <br />Risk Management Division DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCOWMCEW E CYPROVISIONS. <br />20 Civic Center Plaza AUTHORIZED REPRESENTATIVE James Lundi <br />Santa Ana, CA 92702 Risk Managemenf Division <br />a�\°x REVIEWED & APPROVED BY: 1, <br />ACORD 25 (2016/03) 01988-2015 ACORD C , <br />31-1769 11-15 The ACORD name and logo are registered marks of ACORD Risk Management specialist <br />