MELGOZA, JORGE dba ARDENT ERGONOMICS

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Digitally signed by Francine R. Francine R. Villareal _villareal ACC)R"® CERTIFICATE OF LIABILITY INSURANCE wt�d4 �' L� /20/2022 ouzo/zoz2 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT LAZARO NETO NAME: StateFarm LAZARO NETO PHONE (619)-229-6799 FAX(MC. No EauIAIcNo,: (619)-229-6796 3924 EL CAJON BLVD. AIL ADDRESS, lazaro.neto.m36f@statefarm.com • ® INSURERS AFFORDING COVERAGE NAM # INSURER A: State Farm Fire and Casualty Company 25143 SAN DIEGO CA 92105 INSURED INSURER B : MELGOZA, JORGE B INSURER C: 6867 GOLFCREST DR APT 51 INSURER D: NSURER E SAN DIEGO CA 92119 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER - THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADOLSUBR POLICY NUMBER POLICYEFF MMIDD/YYYY POLICYEXP MWOD LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ®OCCUR EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED REMISES Ea occurrence)$ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL &ADV INJURY S 1,000,000 A Y Y 90-E3-KB74-5 10/15/2021 10/15/2022 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY 0 PRO- JECT LOC GENERALAGGREGATE S 2,000,00o PRODUCTS-COMP/OP AGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJ DRV(Per person) $ ANYAUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Per accident ( ) $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE Per accident $ UMBRELLA LIAR Id OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAR CLAIMS -MADE DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNEWEXECUTIVE ❑ OFFICERIMEMBER EXCLUDED? N I A STATUrE ER E.L. EACH ACCIDENT $ E.L. DISEASE EA EMPLOYE $ (Mandatory In NH) If yes, describe under E.L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) The City, its officers, officials, employees, and volunteers are to be covered as additional insureds and waiver of subrogation on the CGL policy with respect to liability arising out of work or operations performed by or on behalf of the Consultant including materials, parts, or equipment furnished in connection with such work or operations SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CITY OF SANTA ANA ACCORDANCE WITH THE POLICY PROVISIONS. 20 CIVIC CENTER PLAZA AUTHORIZED REPRESENTATIVE / � SANTA ANA, CA 92702 .L--� WekManagnrlatDiviaim dti i REVIEWED&APPBOV®Br 01988-2015 ACORD C `I: o IN9pr�:% f�Anr.:.we ,, �lllcvAl ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD ' Risk Managemem Analyst