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ACORD CERTIFICATE OF LIABILITY INSURANCE OP ID 7 DATE (MM DDM YY) THECA -1 06/24/04 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 AUT,101611XIED REPRE IAIIVE Phone:626- 405 -8031 Fax:626- 405 -0585 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: State Compensation Ins Fund MED EXP (Any one person) INSURER B: PERSONAL 8 ADV INJURY $ $ INSURERC: The Cambodian Family 1111 E. Wakeham Ave., Suite E Santa Ana CA 92705 INSURER D. _- 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. LTR NSR TYPE OF INSURANCE POLICY NUMBER P LI Y EFFE TIVE DATE MWDD/VY POLICY EXPI TI N DATE MM/DDNY ) LIMITS P.O. BOX 1988 REPRESENTATIVES. GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS MADE ❑ OCCUR AUT,101611XIED REPRE IAIIVE EACH OCCURRENCE $ PREMISES (Ea occurence) $ MED EXP (Any one person) $ PERSONAL 8 ADV INJURY $ $ GENERAL AGGREGATE GENT AGGREGATE LIMIT APPLIES PER POLICY PRO LOC JECT PRODUCTS - COMP/OP AGG $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS [� Q RO� V1it. " .� - -�� N U COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accidi $ PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY ANY AUTO T;dU (,l Pg5TSV3`T` y AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC AUTO ONLY: AGG $ $ EXCESS/UMBRELLA LIABILITY OCCUR CLAIMS MADE DEDUCTIBLE RETENTION $ EACH OCCURRENCE $ AGGREGATE $ $ $ A WORKERS COMPENSATION AND EMPLOYERS' IETORILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERWEMBER EXCLUDED? Des, describe under SyECIALPROVISIONSbelow 1696570 06/30/03 06/30/04 X TORY LIMITS ER E.L. EACH ACCIDENT $1000000 E.L. DISEASE - FA EMPLOYEE $ 1000000 E.L. DISEASE - POLICY LIMIT - - - -- $1000000 OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS Evidence of Coverage CERTIFICATE HOLDER CANCELLATION SANTANA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL City Of Santa Ana IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR P.O. BOX 1988 REPRESENTATIVES. Santa Ana CA 92702 AUT,101611XIED REPRE IAIIVE ACORD 25 (2001108) © ACORD CORPORATION 1988