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Dlgltallyslgned by Torl Plane,
<br />Torj Pierson Date: 2022,07.1911:13;08
<br />mnrr
<br />ACC>RDV CERTIFICATE OF LIABILITY INSURANCE
<br />OATEIMMIDDIYYYY)
<br />i*�
<br />1 7/5/2022
<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 pollcy(les) 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 />PRODUCER
<br />F and I Insurance Services, Inc.
<br />99 Long Ct.
<br />co TA Yolanda Medina
<br />AME:
<br />PHONEo Eat, (805)496-6555 plc No; Ieoel4a7-7eso
<br />ADDRESS: ymedina@ fandiinsurance. corn
<br />ADDRESS,,
<br />Suite 201
<br />Thousand Oaks CA 91360
<br />INSURERS AFFORDING COVERAGE
<br />NAIC A
<br />INSURERA: Philadelphia Indemnity Insurance Com ar
<br />18058
<br />INSURED
<br />M.T. X-Ray, Inc., DBAI Modern Technology School
<br />16560 Harbor Blvd Suite K
<br />INSURER B: Preferred EmolO ers Insurance
<br />10900
<br />INSURER C: Columbia Casualty Company
<br />31127
<br />INSURER D:
<br />INSURER E :
<br />Fountain Valley CA 92708
<br />INSURER F ;
<br />THIS IS TO CERTIFY THATTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TOTHE INSURED NAMEDABOVE FOR THE POLICY PERIOD
<br />INDICATED. NOTWTHSTANDING 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 />INSR
<br />LT
<br />TYPE OF INSURANCE
<br />ADDL
<br />SUBR
<br />POLICY NUMBER
<br />MMIOID//Y/ Y FEE
<br />MMI�DIYYYY
<br />LIMITS
<br />X
<br />DOM MESCAL GENERAL LIABILITY
<br />EACH OCCURRENCE
<br />$ 11000,000
<br />PREMIDAMAGE RENTED
<br />PREMISES
<br />SESS[Ee occurrence
<br />$ 100,000
<br />A
<br />CLAIMS -MADE % OCCUR
<br />MED EXP(Any one person)
<br />$ 5,000
<br />X
<br />PHPK2430693
<br />07/01/2022
<br />07/01/2023
<br />PERSONAL &ADV INJURY
<br />$ 1,000,000
<br />LIMITAPPLIES PER:
<br />GENERALAGGREGATE
<br />$ 2,000,000
<br />GENLAGGREGATE
<br />X
<br />POLICY ❑ PET LOD
<br />PRODUCTS - COMPIOP ADS
<br />$ 2,000,000
<br />$
<br />OTHER:
<br />AUTOMOBILE
<br />LIA BILITY
<br />COM BINED SINGLE LIM IT
<br />Ea accident
<br />$
<br />11000,000
<br />BODILY INJURY (Per Pelson)
<br />$
<br />A
<br />ANYAUTO
<br />ALL OS SCHEDULED
<br />SAUTOSCHEDULED
<br />BODILY INJURY Per accitlenl
<br />( )
<br />$
<br />AUTOS
<br />PHPK2430693
<br />07 01/2022
<br />/
<br />07/01/2023
<br />HIRED AUTOS X NON -OWNED
<br />AUTOS
<br />X
<br />PROPERTY DAMAGE
<br />Pe accitlenl
<br />$
<br />X
<br />UMBRELLA LIPS
<br />X
<br />OCCUR
<br />EACH OCCURRENCE
<br />$ 1 00,000
<br />AGGREGATE
<br />$ 11000,000
<br />A
<br />EXCESS LIAR
<br />CLAIMS MADE
<br />DID I % I RETENTION $ 10,000
<br />$
<br />1PHUBS20420
<br />07/01/2022
<br />07/01/2023 1
<br />WORKERS COMPENSATION
<br />% PER _
<br />AND EMPLOYERS' LIABILITY YIN
<br />A T TE EERH
<br />E.L. EACH ACCIDENT
<br />$ 1,000,000
<br />ANY PROPRIETOR/PARTNER/EXECUTIVE
<br />OFFICERIMEMBER EXCLUDED? FXI
<br />NIA
<br />B
<br />(Mandatory In NH)
<br />WM147176-11
<br />07/01/2022
<br />07/01/2023
<br />E. L. DISEASE. EA EMPLOYEE
<br />$ 1 000,000
<br />f yes, describe under
<br />E. L. DISEASE -POLICY LIMIT
<br />$ 1,000.000
<br />DESCRIPTION OF OPERATIONS be.
<br />A
<br />Employment Practive Liability
<br />PHSD1713975
<br />07/1/2022
<br />07/1/2023
<br />$1MIU$1 MIL ucll clalMegg Deductible $25k
<br />C
<br />Professional Liability
<br />411936524 (Claims Fade Form)
<br />07/20/2022
<br />07/20/2023
<br />$1 MIU$SMIL occuda,
<br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Addlllonal Remarks Schedule, may be afteched If more space la real ulrml
<br />The City of Santa Ana, its officers, Officials, employees and Volunteers are named as Additional Insured
<br />with respects to the General Liability per form NPI-GLD-VS (05/17)
<br />*10 days notice Of cancellation applies to non-payment of premium, 30 days all Other;
<br />AGoodson@santa-ana.org , W MMvgdnpd.ANaMn
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLIO rAmvms+ yM�pRW®er,
<br />City of Santa Ana THE EXPIRATION DATE THEREOF, NOTICE WILL (II��[It; %d4C Y(f404R
<br />Risk Management Division ACCORDANCE WITH THE POLICY PROVISIONS.
<br />RhkMana9emmcClniplAide
<br />20 Civic Center Plaza
<br />Santa Ana, CA 92702 AUTHORIZED REPRESENTATIVE n.
<br />Jesse Cox, Jr./VAN
<br />© 1988-2014 ACORD CORPORATION. All rights reserved.
<br />ACORO 25 (2014/01) The ACORD name and logo are registered marks of ACORD
<br />INS025 (201401)
<br />
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