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<br />DATE (MM/DD/YYYY)
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<br />CERTIFICATE OF LIABILITY INSURANCE
<br />7/7/2022
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<br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
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<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 />26;32;67!.18(11(
<br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
<br />IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
<br />the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
<br />certificate holder in lieu of such endorsement(s).
<br />CONTACT
<br />PRODUCER
<br />Stacy Grassfield
<br />NAME:
<br />FAX
<br />PHONE
<br />(714)263-3600
<br />(714)263-3600
<br />Lake Insurance Agency
<br />(A/C, No):
<br />(A/C, No, Ext):
<br />E-MAIL
<br />stacy@lakeins.com
<br />653 South B Street
<br />ADDRESS:
<br />Lic #0747473
<br />INSURER(S)AFFORDINGCOVERAGENAIC#
<br />TustinCA92780
<br />Philadelphia Ind. Ins. Co.
<br />INSURER A :
<br />INSURED
<br />Philadelphia Insurance Co.
<br />INSURER B :
<br />The Cambodian Family
<br />State Compensation Insurance Fund35076
<br />INSURER C :
<br />1626 E. 4th Street
<br />United States Liability
<br />INSURER D :
<br />INSURER E :
<br />Santa AnaCA92701
<br />INSURER F :
<br />22-23 GLWCUMB
<br />COVERAGESCERTIFICATENUMBER:REVISIONNUMBER:
<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 />ADDLSUBR
<br />INSRPOLICY EFFPOLICY EXP
<br />TYPE OF INSURANCELIMITS
<br />POLICY NUMBER
<br />LTR(MM/DD/YYYY)(MM/DD/YYYY)
<br />INSDWVD
<br />COMMERCIAL GENERAL LIABILITY
<br />X 1,000,000
<br />EACHOCCURRENCE$
<br />DAMAGE TO RENTED
<br />100,000
<br />CLAIMS-MADEOCCUR$
<br />AX
<br />PREMISES(Eaoccurrence)
<br />XY PHPK23855893/9/20223/9/2023 5,000
<br />MEDEXP(Anyoneperson)$
<br />1,000,000
<br />PERSONAL&ADVINJURY$
<br />3,000,000
<br />GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE$
<br />PRO-
<br />X 1,000,000
<br />POLICYLOCPRODUCTS - COMP/OP AGG$
<br />JECT
<br />Abuse/Molestation Agg.
<br />$
<br />1,000,000
<br />OTHER:
<br />COMBINED SINGLE LIMIT
<br />AUTOMOBILE LIABILITY$
<br />1,000,000
<br />(Eaaccident)
<br />BODILYINJURY(Perperson)$
<br />ANY AUTO
<br />A
<br />ALLOWNEDSCHEDULED
<br />BODILYINJURY(Peraccident)$
<br />X PHPK23855893/9/20223/9/2023
<br />X
<br />AUTOSAUTOS
<br />NON-OWNED
<br />PROPERTY DAMAGE
<br />$
<br />XX
<br />HIRED AUTOS
<br />(Peraccident)
<br />AUTOS
<br />$
<br />1,000,000
<br />Non-owned
<br />UMBRELLA LIAB
<br />X
<br />EACHOCCURRENCE$
<br />1,000,000
<br />OCCUR
<br />EXCESS LIAB
<br />CLAIMS-MADEAGGREGATE$
<br />1,000,000
<br />B
<br />X PHUB8051753/9/20223/9/2023
<br />$
<br />DEDRETENTION$10,000
<br />PEROTH-
<br />WORKERS COMPENSATION
<br />STATUTEER
<br />AND EMPLOYERS' LIABILITY
<br />Y / N
<br />ANY PROPRIETOR/PARTNER/EXECUTIVE
<br />E.L.EACHACCIDENT$
<br />1,000,000
<br />N / A
<br />OFFICER/MEMBER EXCLUDED?
<br />C 9064986216/30/20226/30/2023
<br />(Mandatory in NH)
<br />E.L. DISEASE - EA EMPLOYEE$
<br />1,000,000
<br />Ifyes,describeunder
<br />E.L. DISEASE - POLICY LIMIT$
<br />1,000,000
<br />DESCRIPTION OF OPERATIONS below
<br />Professional Liability
<br />D Professional Liability/Sexual$1,000,000
<br />PHPK23855893/9/20223/9/2023
<br />Liquor Liability
<br />or Physical Abuse/LIQ Liability$1,000,000
<br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
<br />City of Santa Ana, officers, agents, employees, and volunteers are named as additionally insured on this
<br />policy pursuant to written contract, agreement, or memorandum of understanding. Such insurance as is
<br />afforded by this policy shall be primary, and any insurance carried by City shall be excess and
<br />noncontributory30 day cancellation notice applies unless cancelled due to non-payment - 10 days.
<br />CERTIFICATE HOLDERCANCELLATION
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />City of Santa Ana
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />Risk Management Division
<br />20 Civic Center Plaza
<br />AUTHORIZED REPRESENTATIVE
<br />Santa Ana, CA 92702
<br />Bob Lake-C/L/STAGRA
<br />©1988-2014ACORDCORPORATION.Allrightsreserved.
<br />ACORD25(2014/01)TheACORDnameandlogoareregisteredmarksofACORD
<br />INS025 (201401)
<br />
<br />
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