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<br />ACORDrn CERTIFICATE OF LIABILITY INSURANCE I DATE (MMlDDlYYYY)
<br />3/24/2005
<br />PRODUCER 1 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
<br />Arthur J. Gallagher & Co. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
<br />License #0726293 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
<br />505 North Brand Blvd, Suite 600 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW,
<br />Glendale, CA 91203-3944
<br />Phone: 818-539-2300 Fax: 818-539-2301 INSURERS AFFORDING COVERAGE NAIC#
<br />INSURED INSURERA Hartford Casualty Insurance Company 29424
<br />U.S. HealthWorks. Inc. Hartford Fire Insurance Company 19682
<br /> INSURER B
<br />3655 North Point Parkway, Suite 150 American International South Insurance Company 40258
<br />Alpharetta, GA 30005 INSURERC
<br /> INSURER 0 Hartford Insurance Company of the Midwest 37478
<br />, INSURERE
<br />
<br />COVERAGES
<br />
<br /> THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FDA THE POLICY PERIOD INDICATED. NOTWITHSTANDING
<br /> ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
<br /> MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
<br /> POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
<br />II~!>~ ~.~~~ -..-- POLlCY NUMBER POLlCY EFFECTIVE POLlCY EXPIRATION LIMITS
<br />A ~NERAL lIABILlTY 72UENUM8309 09/01/04 09/01/05 EACH OCCURRENCE $ 1,000,000
<br /> X COMMERCIfJ.l. GENERAL LIABILITY ~~EMIS;:::SEaoccurencel $ 300,000
<br /> l CLAIMS MADE 0 OCCUR MED EXP (Anyone person) $ 10,000
<br /> - PERSONAL & ADV INJURY $ 1,000,000
<br /> -.., --...- GENERAL AGGREGATE $ 3,000,000
<br /> ~'LAGG:E~A~i LIMIT APMS PER ~'2..TS - COM~/OP AGG $ 3,000,000
<br /> POLICY ~~,Q;: X LOC
<br />B ~TOMOBILE LIABILITY 72UENUM8309 09/01/04 09/01/05
<br /> COMBINED SINGLE LIMIT $ 1,000,000
<br /> - ANY AUTO (Eaaccidenl)
<br /> - ALL OWNED AUTOS lzM BODILY INJURY
<br /> ~ APPROVED AS TO FO (Per person) $
<br /> SCHEDULED AUTOS
<br /> 0- HIRED AUTOS rltv < ~J //2 BODILY INJURY
<br /> 0- (Peraccidenl) $
<br /> NON-OWNED AUTOS
<br /> L- 7 '-'Laur~ itt jhcCdy PROPERTY DAMAGE $
<br /> {Per accident)
<br /> ==iAGE LIABILITY Assistant j 1& MITT[' ~ AUTOONL Y - EAACCIDENT $
<br /> ANY AUTO OTHER THAN EA Ace $
<br /> AUTO ONLY: AGG $
<br />C ~ESSIUMBRELLA LIABILITY BE2681205 09/01/04 09/01/05 EACH OCCURRENCE $ 15,000,000
<br /> X OCCUR D CLAIMS MADE AGGREGATE $ 15,000,000
<br /> $
<br /> ;1 DEDUCTIBLE _.. $
<br /> X RETENTION $10000 $
<br />0 WORKERS COMPENSATION AND 72WNMG3070 09/01/04 09/01/05 X I T~~~I~N~ I IOJ~-
<br /> F.MPLOYER~' UAerLlTY 1,000,000
<br /> ANY PROPRIETOR/PARTNER/EXECUTIVE E.L EACH ACCIDENT $
<br /> OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $ 1,000,000
<br /> It yes, describe under 1,000,000
<br /> SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $
<br /> OTHER
<br />DESCRIPTION OF OPERATIONS / LOCATIONS {VEHICLESI EXCLUSIONS ADDEO BY ENDORSEMENT {SPECIAL PROVISIONS
<br />*Except 10 days notice for non-payment of premium. The City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California 92701; its officers, employees,
<br />agents, volunteers and representatives are named as additional insureds with regard to liability and defense of suits arising from the operations and uses
<br />performed by or on behalf of the named insured.
<br />
<br />CERTIFICATE HOLDER
<br />
<br />CANCELLATION
<br />
<br />City of Santa Ana
<br />City of Santa Ana Fire Department
<br />
<br />SHOULD ANY OF THE ABOVE oeSCRIBED POLICIES Be CANCELLED BEFORE THE EXPIRATION
<br />DATE THEREOF, THE ISSUING INSURER WILL ~:t:rJ: MAIL ~ DAYS WRITTEN
<br />NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, 1il.J:~.lOiM'l:Ii;.S()(aNlUl(:
<br />
<br />20 Civic Center Plaza
<br />Santa An,a, CA 92701
<br />
<br />ACORD 25 (2001/08)
<br />
<br />JltU{GIBIE:>tm:>08IltSJmOlll;QR(:tJA8Ul:JIt'OO!IJI(~XCNIIXJ9OIlUlI::ftB(INeUQ8Q\>aS~;oe
<br />...............
<br />AUTHORIZED REPRESENTATIVE
<br />
<br />~ .~ \ ~
<br />~ - -" ,~-,-----.
<br />@ACORDCORPORATION 1988
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