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8-31-200S 4:38PM FROM CERTIFICATE OF INSURANCE This certifies that ❑ STATE FARM FIRE AND CASUALTY COMPANY, Bloomington. Illinois ® STATE FARM GENERAL INSURANCE COMPANY, Bloomington, Illinois ❑ STATE FARM FIRE AND CASUALTY COMPANY, Scarborough, Ontario ❑ STATE FARM FLORIDA INSURANCE COMPANY, Winter Haven, Florida ❑ STATE FARM LLOYDS, Dallas, Texas insures the following policyholder for the coverages indicated below: Name of policyholder CASA DE SALUD FAMILY HEALTH CLINIC Address of policyholder 1515 S BROADWAY P-2 LW Location of operations SANTA ANA CA 92707-2211 Description of operations The policies listed below have been issued to the policyholder for the policy periods shown. The insurance described in these policies is subject to all the terms exclusions, and conditions of those policies. The limits of liability shown may have been reduced by any paid claims. POLICY NUMBER TYPE OF INSURANCE POLICY PERIOD Effective Date ! Expiration Data LIMITS OF LIABILITY (at beginning of policy period) F Comprehensive i BODILY INJURY AND Cod, Business Liability PROPERTY DAMAGE - - - ------ -- -- ----- Thls insurance includes -- ----- ...._.....I ........•• -- ❑ Products - Completed Operations ❑ Contractual Liability ❑ Underground Hazard Coverage Each Occurrence $ ❑ Personal Injury ❑ Advertising Injury General Aggregate $ ❑ Explosion Hazard Coverage ❑ Collapse Hazard Coverage Products - Completed $ ❑ Operations Aggregate El EXCESS LIABILITY POLICY PERIOD Effective Date I Expinsdon Date BODILY INJURY AND PROPERTY DAMAGE (Combined Single Limit) ❑ Umbrella Each Occurrence $ ❑ Other Aggregate $ Part 1 STATUTORY Part 2 BODILY INJURY 92 -EU -8430-2 F Workers'Compensation 05/01/2005 05/01/2006 and Employers Liability 05/01/2005 05/01/2006 Each Accident $ 1, 000, 000 Disease Each Employee $ 1, 000, 000 Disease - Policy Limit $ 1, o0o, 000 POLICY PERIOD OMIT$ OF LIABIUTY POLICY NUMBER TYPE OF INSURANCE Effective Date : Expiration Date (at beginning of policy period) THE CERTIFICATE OF INSURANCE IS NOT A CONTRACT OF INSURANCE AND NEITHER AFFIRMATIVELY NOR NEGATIVELY AMENDS, EXTENDS OR ALTERS THE COVERAGE APPROVED BY ANY POLICY DESCRIBED HEREIN. If any of the described policies are canceled before its expiration date, State Farm will try to mail a written notice to the certificate holder 60 Name and Address of Certificate Holder days before cancellation. If however, we fail to mail such notice, no obligation or liability will be imposed on State Farm or its agents or representatives. > /\S ro FORM Stitt Sh--edy City Attorney 55E -9W 4.3 oaa eea Printed In U.S.A. Slgnatun SCOTT r Title anfs( F ("IT i/�O ( V I �" I Cod, /31/2005 Date