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. , DATE (MMlDDNYYY) ACORD. CERTIFICATE OF LIABILITY INSURANCE OP 10 J9 06/24/04 THECA-1 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Chapman & Associates ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE License #0522024 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR P. O. Box 5455 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Pasadena CA 91117-0455 Phone: 626-405-8031 Fax:626-405-0585 INSURERS AFFORDING COVERAGE NAIC# --... -.. - INSURED INSURER A: State Compensation Ins rune! _._-~ INSURER B: The Cambodian Family INSURER c: --- 1111 E. Wakeham Ave., Suite E INSURER 0: Santa Ana CA 92705 -- INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. L TR NSR TYPE OF INSURANCE ~NERAL LIABILITY COMMERCIAL GENERAL LIABILITY I CLAIMS MADE D OCCUR POLICY NUMBER PD~~~1J~DDNtXE Pgk\-CEY(ft~b'}f,R~N LIMITS EACH OCCURRENCE S PREMISES Ea occurence) S MED EXP (Anyone person) S ,__~ERSO~~~~?~I~J~_RY $ GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ --~ .- --..- J- ~'L AGGREGATE LIMIT APPLIES PER: I POLICY n ~r8T n LOC ~TOMOB1LE LIABILITY _ ANY AUTO _ ALL OWNED AUTOS SCHEDULED AUTOS - ._ HIRED AUTOS _ NON.OWNED AUTOS GARAGE LIABILITY ~ ANY AUTO EXCESS/UMBRELLA LIABILITY =:J OCCUR D CLAIMS MADE I DEDUCTIBLE I RETENTION S .,~(\ \,0"" c 0 " 1'-;> O<"J~V ~'~ .___-. ",,\l.C ' '. . I,,,' .___-. 1'-< < !. .. if' .- , /c(d ~,\ ~ .~,,,){n'C' 1..:.\\\1>- , C\ ~ . ';',\'3,J'\\. p...'i>~\ COMBINED SINGLE LIMIT (Eaaccident) . BODILY INJURY (Per person) . BODILY INJURY (Per accident) . PROPERTY DAMAGE (Per accident) . AUTO ONLY - EA ACCIDENT . EA ACC $ AGG $ . . . . . _u_ OTHER THAN AUTO ONLY: EACH OCCURRENCE AGGREGATE ..- A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ~PE(;I~tS~~~VIS~6~S below OTHER 1696570 06/30/03 06/30/04 x IT~~/~I~:f's I IU~~. E.L EACH ACCIDENT S 1000000 El.D!SEASF-EAEMPI.OYFF.: $1000000_~ E.L. DISEASE - POLICY LIMIT $ 10000 0 0 DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS Evidence of Coverage CERTIFICATE HOLDER City of Santa Ana P.O. Box 1988 Santa Ana CA 92702 CANCELLATION SANTANA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL ~ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUT ED REPRE E @ACORD CORPORATION 1988 ACORD 25 (2001/08)