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% CERTIFICATE OF LIABILITYAIXQIi6E
<br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS N RIGHTS UPON THE
<br />CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTE H
<br />BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT N
<br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
<br />a
<br />v y€��yt ) aJ. I Ci 03/24/2022
<br />cLC�TF4fE PIESIS
<br />If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain may require a , endorsel«WAUQJA
<br />this certificate does not confer rights to the certificate holder in lieu of such endorse
<br />nt ).
<br />I f
<br />PRODUCER NAMEAC.
<br />_
<br />Stacy Gmssfleld
<br />Lake Insurance Agency
<br />PHONE
<br />1714)263-3600 nlC (714)263-3600
<br />E
<br />Na:
<br />653 South B Street
<br />E-MA L
<br />s�cy@lakeins.com
<br />la
<br />ADDRESS:
<br />LIc#0747473
<br />INSURERS AFFORDING COVERAGE
<br />NAIC It
<br />Tustin CA 92780
<br />NSURERA:
<br />Philadelphia Ind. Ins. Co.
<br />003616
<br />INSURED
<br />..............
<br />Philadelphia Ind. Ins_ rn.
<br />nngRis
<br />The Cambodian Family
<br />1626 E. 4th Street
<br />I Santa Ana CA 92701 1 INSURER F:
<br />COVERAGES CFRTIFICATP NIIMRFR• 22-23 GLUMB PRO 21-22 rar:rmm�u uuunve.
<br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW NAVE 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 />INSD
<br />MD
<br />POLICYNUMBER
<br />POLICY EFF
<br />MMIDDIYYYY
<br />POLICY EXP
<br />MMIDDIYYYY
<br />LIMITS
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />CLAIMS -MADE 19OCCIIR
<br />EACH OCCURRENCE
<br />$ 11000,000
<br />PREMISES Ea ocwKcNItUam.
<br />$ 100,000
<br />MED EXP (Any one neon
<br />$ 5,000
<br />PERSONAL snov INJURY
<br />$ 1,000,000
<br />A
<br />Y
<br />Y
<br />PHPK2229371
<br />(13109/2022
<br />0=912023.'
<br />GEN'L AGGREGATE LIMITAPPLIES PER:
<br />POLICY ❑ JECT PRo-
<br />LOC
<br />GENERALAGGREGATE
<br />$ 3,000,000
<br />PRODUCTS-COMP/OPAGG
<br />$ 1,000,000
<br />OTHER:
<br />Abuse/MOlestatton Agg.
<br />s 1,000,000
<br />At#t9MO81LELIABILITY
<br />COMBINED SINGLE LIMIT
<br />Me accident
<br />$ 1,000,000
<br />BODILY INJURY (Per person)
<br />$
<br />ANYAUTO
<br />A
<br />OWNED SCHEDULED
<br />AUTOS ONLY X AUTOS
<br />HIRED NON -OWNED
<br />AUTOS ONLY AUTOS ONLY
<br />Y
<br />PHPK2229378
<br />03/0912022
<br />03/09/2023
<br />BODILY INJURY Per accident)
<br />( )
<br />$
<br />PROPERTYDAMAGE
<br />Per accident)
<br />$
<br />Non-ownsd
<br />$ 1,000,000
<br />X
<br />UMBRELLA UAa
<br />OCCUR
<br />EACH OCCURRENCE
<br />$ 1,000,000
<br />AGGREGATE
<br />$ 1,000,000
<br />B
<br />EXCESS LIAR
<br />CLAIMS -MADE
<br />PHUB753959
<br />03/09/2022
<br />03/09/2023
<br />DED
<br />X RETENTION $ 10,000
<br />$
<br />C
<br />W0R(5RSCOMPENSATION
<br />AND EMPLOYERS' LIABILITY YIN
<br />ANY PROPMETORIPARTNERIEXECUTIVE ❑
<br />OFFICER/MEMBER EXCLUDED?
<br />(Mandatory in NH)
<br />If,es, describeDESCRIPTION under
<br />DESCRIPTION OF OPERATIONS below
<br />NIA
<br />906498621
<br />06/30/2021
<br />06/30/2022
<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 />Professional LiabilitylSexual or Physical
<br />Abuse/ Liquor Liability
<br />PHPK2229378
<br />03/09/2022
<br />03/09/2023
<br />Professional Liability
<br />Sexual or Physical Abuse
<br />$1,000,000
<br />$1.000,000
<br />Liquor Liability
<br />1 $1.000,000
<br />DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 1B1, Additional Remarks Schedule, may be attached If more space is required)
<br />City of Santa Ana, officers, agents, employees, and volunteers are named as additionally Insured on this policy pursuant to written contract, agreement, or
<br />memorandum of understanding. Such insurance as Is afforded by this policy shall be primary, and any Insurance tamed by City shall be excess and
<br />noncontributory30 day cancellation notice applies unless cancelled due to non-payment -10 days.
<br />City of Santa Ana Risk Management Division
<br />20 Civic Center Plaza
<br />Santa Ana
<br />CA 92702
<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 />AUTHORIZED REPRESENTATIVE
<br />n
<br />ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
<br />=ia .I,?;� REVIEWEO(16APPROV®
<br />®' RBk Management Sperialist
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<br />
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