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<br />.' <br /> <br />ACORD <br /> <br />INSURED <br />DANIEL RAMIREZ <br />13901 FERNWOOD <br />GARDEN GROVE CA <br /> <br />..1\9<lncy Lic#,' OD28l1L ~___ <br />IV- Jot>3 - o9b <br />tJ- .J.w.l- 0%-01 <br />92843 '-' <br /> <br />I. DATE (MMlDDIYYYY) <br />10/04/2004 <br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION <br />QNL Y AND CONFERS NO RIGHTS UPON THE CERTIFICATE <br />HDLOER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR <br />AL fER THE COVERAGE AFFORDED BY THE POLICIES BELOW. <br />I <br />, INSURERS AFFORDING COVERAGE tAlC # <br /> <br />I~~URERA:,_, ' Ste-ad f,a st I~SU,ranc~ c,omp'~n, y' __ -". _."._ '. -- _ .' -=- <br />INSURER B: <br />-_._--_...__._._-_._-_...~_..._-- <br />INSURERC: ___ __ _~_' __ _l~_ <br />~SURER_~___.________--+_________ <br />i INSURER E: ' <br /> <br />TM, <br /> <br />CERTIFICATE OF LIABILITY INSURANCE <br /> <br />PRODUCER <br />FITNESS AND WELLNESS INSURANCE AGENCY <br />380 STEVENS AVENUE, SUITE 206 <br />SOLANA BEACH CA 92075 <br /> <br />COVERAGES <br /> <br />THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR 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 /> <br />'~i~',~~~~ TYPE OF INSURANCE <br />GENERAL LIABILITY <br />-,:i<J..c.OMMERCIAL GENERAL L1ABILlr; <br />moD CLAIMS MADEI~ OCCUR <br /> <br /> <br />IGEL AGGREGATE L1..;T APPLIES PER: <br />.7: POLICY PROJECT 'I LOC <br /> <br />-~_..~....- <br />POLICY NUMBER <br /> <br />---, <br /> <br />POLIC"EFFiii:CTIVE <br />DATE MMIODIYY <br />11/10/03 <br /> <br />-I PCU~~-EXFIAAT1~-~ r--- <br />DATE MM/DDlYY <br /> <br />LIMITS <br /> <br />EOL5281394-Q0 <br /> <br />11/10/04 <br /> <br />EACH OCCURRENCE __ $ 1 ~OOO.OOO <br />': DAMAGE TO RENTED $ _~OO,OOO_ <br /> <br />MED. EXP {Any one person) ,$ 2,500 <br /> <br />.PERSON~~ & ADV INJURY---~-~OO,OOO <br /> <br />i GENERAL AGGREGATE $ 3,000,000 <br /> <br />PR~~UCTS-CO~P/OP AGG. $ ~_Q.~_'OOO <br /> <br />A <br /> <br />AUTOMOBILE LIABILITY <br />--1 ANY AUTO <br />j ALL OWNED AUTOS <br />: SCHEDULED AUTOS <br />HIRED AUTOS <br />i NON-OWNED AUTOS <br /> <br />COMBINED SINGLE LIMIT <br />(Eaaccident) <br /> <br />$ <br /> <br />BODILY INJURY <br />{Per person) <br /> <br />PROPERTY DAMAGE <br />(Per accident) <br /> <br />-t <br /> <br />,$ <br /> <br />BODILY INJURY <br />; (Per accident) <br /> <br />GARAGE LIABILITY <br />., <br />, ANY AUTO <br /> <br />AUTO ONLY. EA ACl;:IDENT <br /> <br />$ <br />~_ACC $ <br />$ <br /> <br /> <br />i OTHER THAN <br />AUTO ONLY: <br /> <br />1=1 <br /> <br />DEDUCTIBLE <br />RETENTlor~ $ <br /> <br /> <br />/1 2-: <br /> <br />EACH OCCURRENCE ~$ ~_ <br />AGGREGATE $ <br />----- <br />, $ <br />C--=-=-, ~=~$ -- <br />$ <br /> <br />EXCESS I UMBRELLA LIABILITY <br />=.J OCCUR 0 CLAIMS MADE ' <br /> <br />WORKERS COMPENSATION AND <br />EMPLOYERS' LIABILITY <br />, ANY PROPRIETORlPARTNERlEXECUTIVE <br />QFFICERlMEMBER EXCLUDED? <br />Ifye',deacrlbeunder <br />SPECIAL PROVISIONS below <br /> <br /> <br />OTHER <br /> <br />$ <br />..- <br />E.L DISEASE.EA EMPLOYEE ,$ <br />E,L. DISEASE.POLlCY LIMIT $ <br /> <br />OTHER: <br /> <br />DESCRIPTION OF OPERATlONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS <br />CERTIFICATE HOLDER ADDED AS ADDITIONAL INSURED ONLY AS THEIR INTERESTS MAY APPEAR. <br /> <br />The City of Santa Ana <br />20 Civic Center Plaza <br />Santa Ana CA 92701 <br /> <br />CANCELLATION <br /> <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE <br />EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL to <br />DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT BUT <br />FAILURE TO 00 SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE <br />INSURER. Irs AGENTS OR REPRESENTATIVES. <br /> <br />CERTIFICATE HOLDER <br /> <br />AUTHORIZED REPRESENTATIVE <br /> <br />dJL~~ <br /> <br />dj~~. Frick, CEO <br />OD28716 @ACORDCORPORATION 1988 <br /> <br />Attention: <br /> <br />ACORD 25 (2001/08) <br /> <br />Certificate # <br /> <br />9293 <br />