JORGE MELGOZA DBA ARDENT ERGONOMICS

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CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 06/25/2024 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT LAZARO NETO NAME: StateFarm LAZARO NETO q/ No E 619) 29- 99 FAX No : (619)-229-6796 3924 EL CAJON ..� nq i Ao F'E I 6 t NSURER(S�AFFOR NG COVERAGE NAIC # INs /,'E a r I I n 25151 SAN DIEGO C 2105 INSURED It SURLB: tate FarmMfutual Automobile Insurance Company 25178 MELGOZA, JORGE BASURE ate• URER D : 6867 GOLFCREST D5 UREqf) • Q • 1 l ceved INSURER : • • SAN DIEGO CA 921 COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL I SUBR POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE � OCCUR RETE ,REM SES ( DAMAGE ToEa oNcur ence) $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 A Y Y 90-E3-K874-5 10/15/2023 10/15/2024 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO LOC El JECT PRODUCTS - COMP/OP AGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY 583 7885-D15-55A 04/15/2024 10/15/2024 COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ 1,000,000 ANY AUTO A OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ 1,000,000 PROPERTY DAMAGE Per accident $ 1,000,000 HIRED NON -OWNED AUTOS ONLY AUTOS ONLY UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN PER OTH- STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ N I A E.L. DISEASE - EA EMPLOYE $ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 1D1, Additional Remarks Schedule, may be attached if more space is required) City of Santa Ana , its officers, officials, employees, and volunteers are to be covered as additional insureds and waiver of subrogation on the CGL policy with respect to liability arising out of work or operations performed by or on behalf of the Consultant including materials, parts, or equipment furnished in connection with such work or operations CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF Nr)TICF WH I RF nFl IVFRFn IN City of Santa Ana ACCORDANCE WITH THE POLICY PR( ian 20 Civic Center Plaza i R[ele D & APPROgmwntVED ED BY. AUTHORIZED REPRESENTATIVE i' REVIEWED Fz P:PPROVED BY. A+-�:e Acevaolo Santa Ana CA 92702 / %a 1 _ ®' Risk Management Specialist © 1988-2015 ACORD ACORD 25 (2016/03) The ACORD name and logo are regis red marks of ACORD 1001486 132849.12 03-16-2016