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ACRH <br />Samantha Samantsigned <br />ha M. abY <br />CERTIFICATE OF LIABILITY INSt�405zo�ooz °"05/732022 <br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY <br />AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BYTHE POLICIES BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITLMEACONTRACT BETWEEN THE ISSUING INSURER(S), <br />AUTHORIZED REPRESENTATIVE OR PRODUCER, 00 THE CERTIFICATE HOLDER, <br />IMPORTANT If the cerORcats holder Is an ADDITIONAL INSURED, the pulh:y(Les) mud have ADDITIONAL INSURED provisions of he endorsed. IfSUBROGATION IS WAIVED, sub)ectto theta;- and <br />conditions of the Policy, certain policies may require an endorsement Astatementon this certificate does mtoefer rightatothecenthateh0derin Beu otauchemlorsement(s). <br />PRODUCER <br />CONTACT <br />NAME: Theresa Simes <br />Theresa Simes(9744576) <br />17165 Newhope St Ste F <br />PHONE <br />WC, NO, EXD: 714-966-3000 <br />FAX <br />to/C. ND): 714-966-3013 <br />E-MAIL <br />Fountain Valley CA 927084230 <br />ADDRESS: taiMGS@farmemagent.com <br />1%SURER(5)APFORtnNGCOVERAGE <br />NAIC# <br />INSURED <br />INSURERA; Truck Insurance EXChange <br />21709 <br />iN$umaw. Farmers Insurance Exchange <br />2165 2 <br />WYLM H <br />S . TUSTIN ST M.D. <br />67 <br />867 S N <br />INSURER C: Mid Century Insurance Company <br />21687 <br />- <br />INSURERU <br />ORANGE CA 92866 <br />INSURERE: <br />INSURER F: <br />COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: <br />THISISTOCERMFOHATTHEPOUC1E50FINSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAME ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY <br />REQUIREMENT TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCEAFFORDED BY THE <br />POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN RMUCEDBY PAID CLAIMS. <br />I= <br />LTR <br />TYPEOFINSURANCE <br />ADOTL <br />WSO <br />SUBR <br />WVD <br />POLICY NUMBER <br />POLICYEFF <br />(MM1L11C YYJ <br />POLICY BIG, <br />(MM/OD/YYYY) <br />LIMITS <br />A <br />COMMERCIALGENERALUABILRY <br />CLAIMS -MADE OCCUR. <br />Y <br />N <br />602378275 <br />05/29/2022 <br />05/29/2023 <br />EACH OCCURRENCE <br />S 2,000,00 <br />DAMAGE TO RENTED <br />PREMISES(F. Occurrence) <br />$ <br />1,000,00 <br />MEDEXP(Anyoneperson) <br />$ 1000 <br />PERSONAL&ADVINJURY <br />$ 2,OW,000 <br />GENT AGGREGATE LIMIT APPLIES PER; <br />POLICY ❑ PROJECT ❑ LOC <br />OTHER: <br />GENERALAGGREGATE <br />Q 0000 <br />PRODUCTS-COMP/OPAGG <br />S 2,000, <br />$ <br />A <br />ALITOMOBILELIABIUTY <br />ANYAUTO <br />ONNEDAUT05 SCHEDULED <br />HIREDAUTOS X NON -OWNED <br />ONLY AUTOSONLY <br />N <br />r2378275 <br />05129J2022 <br />D5129)2023 <br />COMBINED SINGLE LIMIT <br />Me accident) <br />S 2,000,00 <br />BODILY INJURY (Per person) <br />S <br />BODILY INJURY(P"Uddent) <br />S <br />PROPERTY DAMAGE <br />(Peraccident) <br />$ <br />S <br />LIUMBRELLAUAB <br />ri <br />EXLU: UAB <br />OCCUR <br />CLMMSMADE <br />EACHOCCURRENCE <br />$ <br />AGGREGATE <br />$ <br />OEO RETENTION$ <br />§ <br />WORKERS COMPENSATION <br />AND EMPLOYERS' LIABILITY <br />ANYPROPRIETORIPARCNERJ Y/N <br />EXECUTIVE OFFICER/MEMBER <br />EXCLUDEDT(Mandaturym NH) I <br />Ryas, describe under DESCRIPTION OF <br />OPERATIONS below <br />N/A <br />PER <br />STATUTE <br />OTHER <br />S <br />E.L EACH ACCIDENT <br />$ <br />E.L. OISEASE,EA EMPLOYEE <br />E.L. DISEASE -POLICY LIMIT <br />$ <br />1 <br />T-7 <br />DESCRIPTION OF OPERATIONS LOCATIONS/VEHICLES(ACORD 101, Additlanafks al RemSchedule, may be attached lfinore space is required) <br />867 S TUSTIN ST, ORAN�E, CA 92866 <br />WdtMwbangdl)bidglL <br />�/ REVIEWED&APPRCVEO6Y: <br />IWO <br />4 Risk A9anagementSuperv¢O, <br />CERTIFICATE HOLDER CANCELLATION <br />CITY OFSANTAANARISK MANAGEMENTOIVIISK <br />20 CIVIC CENTER PLZ <br />SHGI"ANYOFTHEABOVEDESCRIB POUCI <br />DATE THEREOF NOTKE WILL BE " EO <br />AUTHORIZEDREPRESENT <br />da(� <br />lXl i <br />ACOR132S(2016/03) <br />17-176q 11-15 <br />®1988-2015 ACORD CORPORATION. All Rights Reserved <br />The ACORD name and Ingo are registered marks of ACORD <br />