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Dy"T"Ilyracylacobsigned <br />Tracy y ). by s <br />,a /�+�-1. p� 'Date: <br />l��V/I� CERTIFICATE OF LIABILITY INSURANCE Jacobs;oo s; <br />DATE (MM/OD/Y1'YV) <br />07TO' 6/16/2022 <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(les) 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('). <br />PRODUCER <br />Chicago, IL -Hub International Midwest West <br />55 East Jackson Boulevard <br />Suite 14th Floor <br />CI11Cag0 IL 60604 <br />CONTACT <br />PHONE <br />1AIr, N9. Exb� 312-922-5000 ac Na:312-922-5358 <br />aooaess: csuchica o hubinternational.com <br />INSURERS AFFORDING COVERAGE <br />NAICB <br />INSURER A: Zurich American Insurance Company <br />16535 <br />License - 100290819 <br />INSURED WELLPAOOm <br />1283 u Holdings, Inc. <br />1283 Murfreesboro Road <br />INSURER B: American Zurich Insurance COm an <br />40142 <br />INSURER C: Texas Insurance Company <br />16543 <br />INSURER D: <br />Suite 500 <br />Nashville TN 37217 <br />INSURERE: <br />INSURER F : <br />uOVERAGES 6CKIII-IUAlt NUMBER:4.92744R79 ACVICV1kI Nlnknoco. <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 />IITR <br />TYPE OFINSURANCE <br />AODL <br />SUBR <br />POLICY NUMBER <br />POLI0 EFF <br />MM/00 <br />POLICY EXP <br />MMIDDeYYYYI <br />LIMITS <br />C <br />X <br />COMMERCIAL GENERAL LIABILITY <br />CLAIMS-MADE1XI OCCUR <br />BLIQSTRTTNO11100_050001_02 <br />3115/2022 <br />3/16/2023 <br />EACH OCCURRENCE <br />$3.000,000 <br />DAMAGETORENTED <br />PREMISES Ea occurrence <br />$100,000 <br />MED UP (Any one person) <br />$ 5,000 <br />PERSONAL$ ADV INJURY <br />$3,000,000 <br />AGGREGATE LIMIT APPLIES PER: <br />1:1PRO- <br />POLICY JECT LOG <br />GENERALAGGREGATE <br />$6,000,000 <br />GEN'L <br />X <br />PRODUCTS-COMPIOPAGG <br />$Included <br />$ <br />OTHER: <br />A <br />AUTOMOBILE <br />LIABILITY <br />BAP 5252136-07 <br />10/1/2021 <br />10/1/2022 <br />COMBINED SEGLELIMIT <br />Ea arcolmmn <br />$2,000,000 <br />X <br />ANY AUTO <br />BODILY INJURY (Par person) <br />$ <br />OWNED SCHEDULED <br />AUTOS ONLY AUTOS <br />BODILY INJURY (Per accident) <br />$ <br />X <br />HIRED X NON -OWNED <br />AUTOS CNLY AUTOS ONLY <br />PROPERTY DAMAGE <br />Per accident <br />$ <br />UMBRELLALIAB <br />Id <br />OCCUR <br />EACH OCCURRENCE <br />$ <br />AGGREGATE <br />$ <br />EXCESS LIAB <br />CLAIMS -MADE <br />DED RETENTION$ <br />$ <br />B <br />A <br />WORKERS COMPENSATION <br />AND EMPLOYERS' LIABILITY YIN <br />ANYPROPRIETOR/PARTNER/EXECUTIVE <br />OFFICER/MEMBEREXCLUDEOP <br />N/A <br />WC5252134-07 AOS) <br />WC5252135-07 WI) <br />10/1/2021 <br />1D/1/2021 <br />10/1/2022 <br />10/112022 <br />X I PER OTH- <br />STATUTE ER <br />E.L. EACH ACCIDENT <br />E,L. DISEASE -EA EMPLOYEE <br />(Mandatory In NH) <br />If yes, describe under <br />EL. DISEASE - POLICY LIMITC <br />DESCRIPTION OF OPERATIONS below <br />MEDICAL PROF LIABILITY <br />(CLAIMS MADE) <br />BUQSTRTTN011100-050001-02 <br />3/15/2022 <br />3/15/2023 <br />PER LOSS EVENT: <br />AGGREGATE: <br />E1,000�OOO <br />DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached If more space Is required) <br />The certificate holder, its officers, officials, employees and volunteers is/are included as additional insured (except workers compensation) where required by <br />written contract. Waiver of subrogation is applicable where required by written contract and subject to policy terms and conditions. This insurance is primary and <br />non-contributory over any existing Insurance and limited to liability arising out of the operations of the named insured subject to policy terms and conditions. <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />Santa Ana, City of <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />, <br />20 Civic Center Plaza Santa Ana CA 92701 - <br />AUTHORIZED REPRESENTATIVE <br />f �� RWcM�raROD. <br />REVIEWED FiAPP/WPROVDm Y <br />BY.- <br />�n Twy <br />© 1988-2015 ACORD CORF 49-0.W Rrtk ManagemeRrAnalysr <br />ACORD 25 (2016/03) The ACORD name and logo are registered ITT <br />