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DATE(MM/DD/YYYY) <br /> ACCOR" CERTIFICATE OF LIABILITY INSURANCE <br /> 08/14/2025 <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 policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. <br /> If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on <br /> this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). <br /> PRODUCER CONTNAMEACT Automatic Data Processing Insurance Agency, Inc. <br /> Automatic Data Processing Insurance Agency, Inc. A//C,No Ext: 1-800-524-7024 (A///C,No): <br /> E-MAIL <br /> ADDRESS: <br /> 1 Adp Boulevard INSURER(S)AFFORDING COVERAGE NAIC# <br /> Roseland NJ 07068 INSURERA: Rated by Multiple Companies <br /> INSURED Jacob Green And Associates Inc. INSURER B: <br /> INSURER C: <br /> 13217 Jamboree Rd#248 INSURER D: <br /> INSURER E: <br /> Tustin CA 927829158 INSURER F: <br /> COVERAGES CERTIFICATE NUMBER: 4485224 REVISION NUMBER: <br /> THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD <br /> INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS <br /> CERTIFICATE MAY BE 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS <br /> LTR INSD WVD POLICY NUMBER MMIDD/YYYY MMIDD/YYYY <br /> COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ <br /> CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ <br /> MED EXP(Any one person) $ <br /> PERSONAL&ADV INJURY $ <br /> GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ <br /> POLICY❑ PRO JECT ❑ LOC PRODUCTS-COMP/OP AGG $ <br /> OTHER: $ <br /> AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ <br /> (Ea accident) <br /> ANY AUTO BODILY INJURY(Per person) $ <br /> OWNED SCHEDULED BODILY INJURY(Per accident) $ <br /> AUTOS ONLY AUTOS <br /> HIRED NON-OWNED PROPERTY DAMAGE $ <br /> AUTOS ONLY AUTOS ONLY (Per accident) <br /> UMBRELLA LAB OCCUR EACH OCCURRENCE $ <br /> EXCESS LIAB CLAIMS-MADE AGGREGATE $ <br /> DED RETENTION$ $ <br /> WORKERS COMPENSATION PER OTH- <br /> Y/N <br /> AND EMPLOYERS'LIABILITY STATUTE ER <br /> ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 <br /> A OFFICER/MEMBER EXCLUDED? N/A Y 76WEGAS7GJL 05/24/2025 05/24/2026 <br /> (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 <br /> If yes,describe under 1,000,000 <br /> DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ <br /> DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) <br /> This certificate has a blanket Waiver of Subrogation for the following state(s):CA <br /> PPROVED <br /> y To Train Nguyen at 12a7 pm,Aug,14,20�0, <br /> CERTIFICATE HOLDER CANCELLATION ---------------------------------- <br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br /> THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br /> City of Santa Ana ACCORDANCE WITH THE POLICY PROVISIONS. <br /> Attention: Human Resources-Lori Schna <br /> 20 CIVIC CENTER PLZ#M-24 FL 5 AUTHORIZED REPRESENTATIVE <br /> Santa Ana CA 92701 <br /> ©1988-2015 ACORD CORPORATION. All rights reserved. <br /> ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD <br />