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CERTIFICATE OF LIABILITY INSURANCE DATEIMMIDDIYYYY) 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(les) 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 INAMEACT Name of Contact Person for Insurance Broker/Agent Name of Insurance Broker / Insurance Agent PHONE XXX X M. No Ex[1' ( ) XX-XXXX _.iL� No: (XXX) XXX-XXXX Address ADDRESS: XXXXXXXXXXXXXXQXXXXXXXXXXXXXXXXXXXX.XXX Address _-_--- INSURED Name of Vendor Vendor's Contact Person/Department Address Phone No. rnVERArF4 rcoTIClr ATv au move. Name of Insurance Carder License # Name of Insurance Cartier License # Name Name of Insurance Cartier _ of Insurance Carrier _ _ _ License # License # Name of Insurance Carrier License # Name of Insurance Carrier _ License # 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. I LTR TYPEOFINSURANCE INISMI POLICYNUMBER EFF PMIoDY POLICY UP MMMDNY LIMBS X I COMMERCIAL GENERALLIABILITY EACH OCCURRENCE $ 1,000,000.00 CLAIMS-MIIDE a OCCUR $ For LeaselRental p PREMS RCJDA—MIsETORENTEDES Ea oacu n e $ Can be blank MED EX? (My one person) PERSONAL& ADV INJURY S 1,000,000.00 Y Y XXXXXX-XXXXX-XXXXXX-XX I Valid From Valid To AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,0B0.00 GENL X POLICY PEa 11LM PRODUCTS - COMP/OP AGG $ 2,000,000.00 OTHER: $ AUTOMOeILELIABILM COMaINEDSINGLE MR Be e,ldeot $ 11000,000.00 - OF X, ANY AUTO BODILY INJURY (Per P,,mo) $ 1,000,000.00 B OWNED SCHEDULED —I 'AUTOS ONLY AUTOS Y Y XXXXXXX-XXXXXXX-XXXXX (Valid From Valid To a001LY INJURY (PeresYtlany $ 2,000,QOO.00 HIRED I NON -OWNED "AUTOS ONLY AUTOS ONLY PROPERTYDAMAGE JPvF a¢itlenl S 1,000,000.Go $ X UMBRELLA LIAR X OCCUR FACH OCCURRENCE g 5,000,000.00 C X EXCESS LIAB CLAIMSAIADE Y Y XXXXXX-XXXXXX-XXXXXXX Valid From Valid To AGGREGATE $ S,DDQDDD.DD DEO I I RETENTIONS $ WORKERS COMPENSATIONOTH X PER AND EMPLOYERS' LIABILITY YIN FIR STATUTE ER E.L EACH ACCIDENT $ 1,000,000.06 D OF CEW MB RD(C UDED?ANYPROPRIE'TOWPARTNERiDIECUTIVE M NIA Y XXXXX-XXXXXX-XXXXXXXX Valid From Valid To E.L. DISEASE -EA EMPLOYEE $ 1.000.000.00 (Mandatary In NH) II yes, antler E.L DISEASE -POLICY LIMIT $ 1,000,000.00 IPTIOa DESCRIPTION OF OPERATIONS below Sexual Abuse & Molestation Each Occurrence $1,000,000.00 lip Professional Liability Y Y XXXXXX-XXXXXX-XXXXXXX Valid From Valid To or Claim $11000,000.00 Aggregate $2.000,000.00 DESCRIPTION OF OPERATIONS ( LOCATIONS I VEHICLES IACONO 101, Additional Remarks schedule, may be attached ifmara.p.o Is n q.had) Location! Address / Name of Project / Event / Etc. Identifying information only. City of Santa Ana Attention: Department or Department Representative Name Address of Department, M-XX Santa Ana, CA 92701 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Signature of Insurance Broker/Agent is necessary ®1988-2015 ACORD CORPORATION. All rights ACUKU ZO (ZU1ti/U3) The ACORD name and logo are registered marks of ACORD