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Samantha M,DIglt llysignedby
<br />Samantha M. Lambert
<br />I �mhort nate:2022.06.13
<br />,aacw aroo� CERTIFICATE OF LIABILITY INSURANCE
<br />�
<br />DATE(MMIDD/YYYY)
<br />03/24/2022
<br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
<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 />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
<br />IMPORTANT., If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED 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
<br />NAME CT Stacy Grassfeld
<br />Lake Insurance Agency
<br />PHONE (714)263-3600 AX
<br />AI pIC Ne: (714)263-3600
<br />653 South B Street
<br />E-MA LESS: cy@lakeins.com
<br />Lic #0747473
<br />ADDR
<br />INSURERS AFFORDING COVERAGE
<br />NAIC #
<br />Tustin CA 92780
<br />INSURERA: Philadelphia Ind. Ins. Co.
<br />003616
<br />INSURED
<br />INSURER 9: Philadelphia Ind. Ins. Co.
<br />003616
<br />The Cambodian Family
<br />State Compensation INSURER C: P cation Insurance Fund
<br />35076
<br />1626 E. 4th Street
<br />INSURER D
<br />INSURER E:
<br />Santa Ana CA 92701 1
<br />INSURERF:
<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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
<br />CERTIFICATE MAYBE 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 />LTR
<br />TYPE OF INSURANCE
<br />INSD
<br />MD
<br />POLICY NUMBER
<br />MMIDDNYYYY
<br />MMIDDIYYYY
<br />LIMITS
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />NA
<br />EACH OCCURRENCE
<br />$ 1,000,000
<br />PREMISES 1E, occunen
<br />$ 1001G00
<br />CLAIMS -MADE OCCUR
<br />MED EXP (My one erson
<br />$ 5,000
<br />PERSONAL III INJURY
<br />$ 11000,000
<br />A
<br />Y
<br />Y
<br />PHPK2229378
<br />03/09/2022
<br />03/09/2023
<br />GENT AGGREGATE LIMITAPPLIES PER:
<br />PI
<br />GENERALAGGREGATE
<br />$ 3,000,000
<br />PRODUCTS -COMPMP AGO
<br />It 1.000,000
<br />POLICY JECTPRO- ❑OC
<br />OTHER
<br />I
<br />Abuse/Molestation Agg.
<br />$ 1,000,000
<br />AUTOMOBILE
<br />LIABILITY
<br />COMBINED SINGLELIMIT
<br />Ea accident
<br />$ 1,000,000
<br />ANYAUTO
<br />BODILY INJURY (Per Gerson)
<br />S
<br />A
<br />OWNED SCHEDULED
<br />AUTOS ONLY X AUTOS
<br />Y
<br />PHPK2229378
<br />03/09/2022
<br />IX
<br />03/09/2023
<br />BODILY INJURY Per accident)
<br />$
<br />HIRED NONOWNEp
<br />AUTOS ONLY X AUTOS ONLY
<br />PROPERTY DAMAGE
<br />(Per accident
<br />$
<br />Non -owned
<br />$ 1,000,000
<br />X
<br />UMBRELLA LIAR
<br />OCCUR
<br />EACH OCCURRENCE
<br />$ 1.000,000
<br />03/09/2023
<br />AGGREGATE
<br />$ 11000,000
<br />B
<br />EXCESS LIAR
<br />CLAIMS -MADE
<br />PHUB753959
<br />03/09/2022
<br />DED I X RETENTION $ 10,000
<br />WORKERS COMPENSATION
<br />PER_
<br />X
<br />$
<br />AND EMPLOYERS LIABILITY YIN
<br />STATUTE FORT
<br />E.L. EACH ACCIDENT
<br />S 11000,000
<br />C
<br />ANY PROPRIETOWARTNEWEXECUTIVE
<br />OFFICERTOEMBER EXCLUDED?
<br />NIA
<br />906498621
<br />06/30/2021
<br />06/30/2022
<br />(MandatoryIn NH)
<br />If yes, (Mandatory
<br />I e antler
<br />E.L. DISEASE - EA EMPLOYEE
<br />$ 1,000,000
<br />E.L. DISEASE -POLICY LIMIT
<br />$ 11000,000
<br />DESCRIPTION OF OPERATIONS below
<br />Professional Liability/Sexual or Physical
<br />Professional Liahility
<br />$1,000,000
<br />A
<br />Abuse/ Liquor Liability
<br />PHPK2229378
<br />03/09/2022
<br />03/09/2023
<br />Sexual or Physical Abuse
<br />$1,000,000
<br />Liquor Liability
<br />$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 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 Carried by City shall be excess and
<br />noncontributory30 day cancellation notice applies unless cancelled due to non-payment -10 days.
<br />SHOULD ANY OF THE ABOVE DESCR
<br />THE EXPIRATION DATE THEREOF, NC
<br />City of Santa Ana Risk Management Division
<br />ACCORDANCE WITH THE POLICY PR
<br />20 Civic Center Plaza
<br />AUTHORIZED REPRESENTATIVE
<br />Santa Ana CA 92702
<br />9)1988-2015 ACORD
<br />ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
<br />'�sfy- yalr AvrtLlol#gvnRcvE lEhn
<br />3�r, REVIEWED i4 /WPRovEO BY:
<br />'N.cailGc ia*�rtiY
<br />� ' Ruk Management Supervisor
<br />All rights reserved.
<br />
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