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<br />AkCiBD CERTIFICATE OF LIABILITY INSURANCE I DATE (MMIDDIYYYY)
<br /> '" 12/02/2003
<br />PRODUCER (909) 587-2719 FAX (909)587-6001 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
<br />Anthem Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
<br />42145 Lyndie Ln., #202 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
<br /> ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
<br />Temecula, CA 92591
<br />License # OB84551 INSURERS AFFORDING COVERAGE NAIC#
<br />INSURED Boys and Girls Club of Santa Ana INSURER A" Markel Insurance Company
<br /> 950 Highland St INSURER B.
<br /> Santa Ana, CA 92703 INSUH.ER c:
<br /> INSURER 0:
<br /> INSURER E
<br />
<br /> THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDINI
<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 />1~~~ ~R.9:~ ' POLICY EFFECTIVE POLICY EXPIRATION
<br /> TYPE OF INSURANCE POLlCY NUMBER LIMITS
<br /> ~NERAL LIABILITY 8502CY073003 12/20/2003 01/05/2005 EACH OCCURRENCE $ 1 , OOO_,J.IQ!J
<br /> COMMERCIAL GENERAL LiABllr,y I ~~~~~~¿ 9L:~EN i ED I 50,000
<br /> -] CLAIMS MADE D OCCUR ~~p (Anyone parson) $ 5,000
<br />A X - PERSONAL & AOV INJURY I 1,000,000
<br /> GENERAL AGGREGATE , 3,000,000
<br /> - ,-
<br /> GEN'L AGGREGATE LIMIT APPLIES PER" PRODUCTS ~ COMP/OP AGG ' 1,000,000
<br /> h .-Fl PRO, n
<br /> POLICY JEcr lOC
<br /> ~TDMOBILE LIABILITY 1002CYC0730044 12/20/2003 01/05/2005 COMBINED SINGLE LIMIT
<br /> ,
<br /> ANY AUTO (Ea accident) 1,000,000
<br /> ~
<br /> f---- ALL OWNED AUTOS 80DIL Y INJURY
<br /> [\S ,\,0 (Per person) ,
<br /> . SCHEDULED AUTOS
<br />A X ~ , (\O'J'£.D ,.'
<br /> f---- HIREiJ AU ros L17 ~~ BODILY INJURY
<br /> "{b l~~ (Per accident) ,
<br /> ~ NON-OWNED AUTOS J..--- - ...
<br /> H ~ S\'O\1.(",I<'. PROPERTY DAMAGE ,
<br /> ~-- \..ISp.. '",,\1 p\lW¡í'll'\! (Per accident)
<br /> lAGE LIABILITY r>,SSISt3\ \ VI of J D AUTO ONLY - EA ACCIDENT $
<br /> ANY AUTO --- OTHER THAN EA ACC ,
<br /> " AUTO ONLY' AGG ,
<br /> 5ESS/UMBRELLA LIABILITY 4602CY0730105 12/20/2003 01/05/2005 EACH OCCURRENCE , 5,000,000
<br /> OCCUR 0 CLAIMS MADE AGGREGA T[ $ 5,000,000
<br />A X I '
<br /> M DEOUCTIBLE $
<br /> X RETENTION $ 10,00Ð $
<br /> WORKERS COMPENSATION AND ITv,;~.7'T{';Jg;,,1 10J,i"
<br /> EMPLOYERS' LIABILITY
<br /> ANY PROPRIETORfPARTNERJEXECUTIVE EL EACH ACCIDENT ,
<br /> OFFICER/MEMBER EXCLUDED? ~_p..SE - EA EMPlOYEEI $
<br /> If ye~. describe under
<br /> SPECIAL PROVISIONS below , E_L- DISEASE - POLICY LIMIT $
<br /> OTH~
<br /> 10 ay cancel non
<br /> payment of premium
<br />DESCRIPTION OF OPERATIONS ¡lOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
<br />"E: Certi fi cate holder is named as additional insured as respects to additional insured endorsement
<br />flttached.
<br />
<br />COVERAGES
<br />
<br />Sanêa Ana WIBjYC
<br />Anabel 1 Bates, Youth
<br />P.O. Box 1988-M-73
<br />Santa Ana, CA 92702
<br />
<br />CANCELLATION
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
<br />EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ~x~ MAIL
<br />~ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
<br />
<br />CERTIFICATE HOLDER
<br />
<br />Council Coordinator
<br />
<br /> (iXIJOO(JúIój(~X¡( (~)(ü()@(¡j(:Jó ()(i}(JI\~J(¡ jJó1óXIi6. (iJOO(XX
<br />¡¡iOOVJØij[¡XM¡¡!(j(¡Jé)OO(¡XI>A(X-XXIßó tXJl\ ()(øx~XXXXXXXX
<br />
<br />
<br />(Ç)ACORD CORPORATION 1988
<br />
<br />ACORD 25 (2001108)
<br />
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