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CORD_- CERTIFICATE LIABILITY INSURANC 03OP 50750 R DATE (MM OD/03 <br />57 03 28 03 <br />PRO <br />UCER <br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION <br />Fi <br />ness & Wellness Insurance <br />ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE <br />Ag <br />38 <br />incy <br />Stevens Ave., First Floor <br />HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR <br />ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. <br />So <br />ana Beach CA 92075 <br />Ph <br />one:800-395-8075 Fax:858-519-0822 <br />INSURERS AFFORDING COVERAGE <br />NAIC# <br />INSL <br />RED <br />INSURER A: Specialty National Insurane <br />INSURER B: <br />Choc V. Le #0375057 <br />8ff: 01-06-03 <br />INSURERC: <br />INSURER D: <br />4 Firiano <br />Irvne CA 92620 <br />INSURER E: <br />CO <br />&RAGES <br />TI <br />IE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING <br />AJ <br />Y REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR <br />V PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH <br />POLICIES. <br />AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br />LTR <br />NIJIJ� <br />SR <br />TYPE OF INSURANCE <br />POLICY NUMBER <br />FULICT EFFECTIVE <br />DATE MMID <br />POLICY EXPIRATION <br />DATE MWD <br />LIMITS <br />GENERAL LIABILITY <br />EACH OCCURRENCE <br />S1,000,000 <br />A <br />X <br />X COMMERCIAL GENERAL [ABILITY <br />3XZ126451-02 <br />01/06/03 <br />01/06/04 <br />PREMISES (Ea xarence) <br />$100,000 <br />CLAIMS MADE FX] OCCUR <br />MED EXP (Any we Person) <br />S2,500 <br />PERSONAL SADVINJURY <br />$1,000,000 <br />A <br />X Nisc.Professional <br />GENERAL AGGREGATE <br />S3,000,000 <br />GENL AGGREGATE LIMIT APPLIES PER: <br />PRODUCTS -COMPIOPAGG <br />S1,000,000 <br />POLICYF—j JECT F-ILOC <br />AUTOMOBILE <br />LIABILITY <br />ANY AUTO <br />COMBINED SINGLE LIMIT <br />(Ea accident) <br />$ <br />BODILY INJURY <br />(Per Person) <br />$ <br />ALL OWNED AUTOS <br />SCHEDULED AUTOS <br />BODILY INJURY <br />(Per accident) <br />S <br />HIRED AUTOS <br />NON -OWNED AUTOS <br />PROPERTY DAMAGE <br />(Par accident) <br />S <br />GARAGE LIABILITY <br />AUTO ONLY• EA ACCIDENT <br />S <br />OTHER THAN EA ACC <br />$ <br />ANY AUTO <br />S <br />AUTO ONLY: AGO <br />EXCESSAIMBRELLA LIABILITY <br />EACH OCCURRENCE <br />$ <br />OCCUR CLAIMS MADE <br />AGGREGATE <br />$ <br />S <br />$ <br />DEDUCTIBLE <br />$ <br />RETENTION $ <br />WORKERS COMPENSATION AND <br />EMPLOYERS' LIABILITY <br />ANY PROPRIETOR/ PARTNERIEXECUTNE <br />WL' <br />TORY LIM5TABS ER <br />E.L. EACH ACCIDENT <br />$ <br />E.L. DISEASE • EA EMPLOYE <br />$ <br />OFFICER(MEMBER EXCLUDED? <br />tt yes. AL cribePRO ISIO <br />SPECIAL PROVISIONS below <br />E.L. DISEASE •POLICY LIMIT <br />S - <br />OTHER <br />A <br />Sexual Abuse <br />3XZ126451-02 <br />100,000 <br />300,000 <br />)ES <br />It <br />RIPTIONOFOPERATIONSILOCATIONSIVEHICLESIEXCLUSIONSADDEDBYENDORSEMENTISPECIALPROVISIONS APPROVED AS ILA FORM <br />is understood and agreed City of Santa Ana, its officers, agents, <br />employees, <br />representatives, and volunteers are added as addition <br />in <br />uered per the attached form CG201011/85 <br />LRL .-,ihcedy <br />I)cpuly City Attorney <br />;E <br />TIFICATE HOLDER CANCELLATION <br />SANANAC <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION <br />DATE THEREOF, 30 DAYS WRITTEN <br />City of Santa Ana Parka and <br />Recreation, & Community <br />NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, <br />Services Agency <br />P.o. Box 1988 N-23 <br />AUTHORIZED REPRESENTATIVE <br />Santa Ana CA 92702 <br />Jeffrev E. Frick <br />25 (2001I08) 0 ACORD CORPORATION 1988 <br />