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<br />ACOROOM CERTIFICATE OF WORKERS' COMPENSATION COVERAGE I DATE (MMfDDfYY) <br /> 2/1/2005 <br /> THIS CERTIFICATE IS ISSUED AS MATTER OF INFORMATION <br />PRODUCER ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE <br /> HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR <br />Driver Alliant Insurance Services, Inc. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. <br />The Transamerica Pyramid <br />91h INSURERS AFFORDING COVERAGE <br />600 Montgomery Street, Floor <br />San Francisco, CA 94111 <br />INSURED INSURER A: NonProfits' United - Workers' Compensation GrOUD <br /> INSURER B: Grav Insurance Company <br />AIDS Services Foundation of Orange County, Inc. INSURER c: Insurance Corporation of Hannover <br />17982 Sky Park Circle, Suite J INSURER D- <br />Irvine, CA 92614 <br /> INSURER E <br /> <br />COVERAGES ThiS Certificate is not intended to specify all endorsements coverages terms conditions and exclusions of the poliCies shown <br /> <br /> THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. <br /> NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY <br /> BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND <br /> CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br /> INSR TYPE OF INSURANCE POLICY NUMBER POLl~;1 EFFECT~E POLICY EXPIRATION LIMITS <br /> LTR DATE MMJDD/YV DATE MM/DD/YY <br /> GENERAL LIABILITY EACH OCCURRENCE 5 <br /> - COMMERCIAL GENERAL LIABILITY <br /> FIRE DAMAGE (Anyone fire) S <br /> - ~ CLAIMS MADE D OCCUR MED EXPENSE (ArijOllB pe~on) $ <br /> - PERSONAL & ADV INJURY $ <br /> - GENERAL AGGREGATE <br /> $ <br /> <3EN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $ <br /> I nPRO-n <br /> POLICY JECT LOC <br /> AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT . <br /> - ANY AUTO (Eaaccident) 5 <br /> - ALL OWNED AUTOS APPROVED AS TO j \-.. <br /> BODILY INJURY $ <br /> - SCHEDULED AUTOS /L' -6 (Per person} <br /> $ <br /> - HIRED AUTOS ~/,f BODILY INJURY . <br /> - -. (Per accident) <br /> NON+OWNED AUTOS Laulu tHI , <br /> - '\i,,~ _'-, <br /> Asslstanl ,[y '\lll'{:l~:. PROPERTY DAMAGE $ <br /> - (Peraccidenl) $ <br /> GARAGE LIABILITY AUTO ONLY EA ACCIDENT 5 <br /> ~ ANY AUTO OTHER THAN EA ACC $ <br /> AUTO ONLY: <br /> AGG $ <br /> EXCESS LIABILITY EACH OCCURRENC $ <br />- -~- --..- __---.r:--1 "" ......._....."'L_ - - ---~~- <br /> -- - ---- <br /> . -- . .- .-- - - - <br /> R DEDUCTIBLE . <br /> RETENTION <br /> WORKERS' COMPENSATION AND I WC STATU- I xT OTH- <br /> EMPLOYERS LIABILITY TORY LIMITS ER <br /> NPU - WCG D01 2/1/2005 1/1/2006 E.L. EACH ACCIDENT $500,000 <br /> A E.L. DISEASE EA EMPLOYEE .500,000 <br /> E.L. DISEASE POLICY LIMIT .500,000 <br /> OTHER B = GCR 04-02-221 B - $500,000 X $500,000 <br /> B&C Excess Worker's Compensation <br /> C = H35-0402489 2/1/2005 1/1/2006 C = $25,000,000 x <br /> $1,000,000 <br /> DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAUPROVISIONS <br /> Evidence of Coverage of Workers' Compensation <br /> CCPO"!'(,!C ,.d O-')c PL'''' <br /> # ._U "-i ,,-,,,_1 ,"UH_ 'Lij,.~ !i~~,_ <br /> CERTIFICATE HOLDER ADDITIONAL INSURED; INSURER LETTER: CANCELLATION <br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION <br /> City of Santa Ana DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL -"- DAYS WRITTEN <br /> 20 Civic Center Plaza NOTiCE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL <br /> P.O. Box 1988 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ~AGENTS OR <br /> Santa Ana, CA 92702 REPRESENTATIVES ....... /"7. I <br /> AUTHQRIZEDREPRESENTATIVE (' ~ t- /P;Lj __V <br /> --; <br /> <br />G\Share\csg\doc\pcrmIAlpha\NonProfits' UnitedlCel1s oflnsurallcelNPU WCG Certificate OlO!05 doc <br />