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<br />A1 b OSSHART
<br />144c74-�ofzo„ CERTIFICATE OF LIABILITY INSURAN
<br />Acev qM/DD/YYYY)
<br />/2022
<br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO S1 C
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<br />CERTIFIBELOW. CATE DOES NOT EXTEND
<br />FOFwATOR IOTLCO
<br />THIS CERTIFICATE INSURANCE DOES NIVELY
<br />STIV UTECONTRACT BETWEEN THE ISSI;IN,G
<br />INSUREEtWAIHQ6tY&
<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
<br />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 License # OM10410
<br />CONTACT
<br />NAME:
<br />PHONE
<br />(A/C, No, Ext): (949) 381-7700
<br />FAX
<br />, No):(949) 861-9429
<br />Armstrong/Robitaille/Riegle Business and Insurance Solutions
<br />1500 Quail St, Suite #100
<br />Newport Beach, CA 92660
<br />E-MAILarrinfo@aleragroup.com
<br />INSURERS AFFORDING COVERAGE
<br />NAIC #
<br />INSURERA: Great American Insurance Co.
<br />16691
<br />INSURED
<br />INSURERB:Insurance Co of the West
<br />27847
<br />Benevolent & Protective Order of Elks #794
<br />Elks Building Association of Santa Ana
<br />INSURER C :
<br />1751 S. Lyon St
<br />INSURER D :
<br />INSURER E :
<br />Santa Ana, CA 92705
<br />INSURER F :
<br />COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
<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 />LTR
<br />TYPE OF INSURANCE
<br />ADDL
<br />INSD
<br />SUBR
<br />WVD
<br />POLICY NUMBER
<br />POLICY EFF
<br />MMIDD/YYYY
<br />POLICY EXP
<br />MMIDD/YYYY
<br />LIMITS
<br />A
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />CLAIMS -MADE X OCCUR
<br />X
<br />PAC395275101
<br />5/29/2022
<br />5/29/2023
<br />EACH OCCURRENCE
<br />$ 1,000,000
<br />DAMAGE TO RENTED
<br />PREMISES Ea occurrence
<br />1,000,000
<br />$
<br />MED EXP (Any oneperson)
<br />$ 10,000
<br />PERSONAL & ADV INJURY
<br />$ 1,000,000
<br />GEN'L
<br />X
<br />AGGREGATE LIMIT APPLIES PER:
<br />POLICY PELT LOC
<br />OTHER:
<br />GENERAL AGGREGATE
<br />$ 2,000,000
<br />PRODUCTS-COMP/OPAGG
<br />$ 2,000,000
<br />$
<br />A
<br />AUTOMOBILE
<br />LIABILITY
<br />ANY AUTO
<br />OWNED SCHEDULED
<br />AUTOS ONLY AUTOS
<br />HIRED X NON -OWNED
<br />AUTOS ONLY AUTOS ONLY
<br />PAC395275101
<br />5/29/2022
<br />5/29/2023
<br />COMBINED SINGLE LIMIT
<br />Ea accident
<br />1,000,000
<br />$
<br />BODILY INJURY Perperson)
<br />$
<br />BODILY INJURY Per accident
<br />$
<br />X
<br />PROPERTY DAMAGE
<br />Per accident
<br />$
<br />A
<br />X
<br />UMBRELLA LIAB
<br />EXCESS LIAB
<br />X
<br />OCCUR
<br />CLAIMS -MADE
<br />UMB395275201
<br />5/29/2022
<br />5/29/2023
<br />EACH OCCURRENCE
<br />$ 1,000,000
<br />AGGREGATE
<br />$ 1,000,000
<br />DED X RETENTION $ 10,000
<br />$
<br />B
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY
<br />Y/N
<br />ANY PROPRIETOR/PARTNER/EXECUTIVE ❑
<br />OFFICER/MEMBER EXCLUDED?
<br />(Mandatory in NH)
<br />If yes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />N/A
<br />WSD506302200
<br />12/5/2021
<br />12/5/2022
<br />X PER OTH-
<br />STATUTE ER
<br />E.L. EACH ACCIDENT
<br />1,000,000
<br />$
<br />E.L. DISEASE- EA EMPLOYEE
<br />$ 1,000,UUU
<br />E.L. DISEASE - POLICY LIMIT
<br />1,000,000
<br />$
<br />A
<br />A
<br />Abuse & Molestation
<br />Abuse & Molestation
<br />PAC395275101
<br />PAC395275101
<br />5/29/2022
<br />5/29/2022
<br />5/29/2023
<br />5/29/2023
<br />Each Abuse Limit
<br />Aggregate Limit
<br />1,000,000
<br />2,000,000
<br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
<br />City of Santa Ana is included as Additional Insured as respects General Liability per the attached forms.
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />City of Santa Ana THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />ty ACCORDANCE WITH THE POLICY PROVISIONS.
<br />20 Civic Center Plaza
<br />Santa Ana, CA 92701
<br />AUTHORIZED REPRESENTATIVE
<br />Risk kluagment DlMsian
<br />Lt,mt,....,`f y ;� ° REVIEWED&APPROVED BY.-
<br />ACORD 25 (2016/03) © 1988-2015 ACORD I 4 e Aeevaa
<br />The ACORD name and logo are registered marks of ACORD Risk Management Specialist
<br />
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