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<br />. ACORD <br />- '---TM <br /> <br />PRODUCER (714)838-1912 <br />Lake Insurance Agency <br />13891 Newport Ave., Suite 285 <br />L ic #0747473 <br />Tustin, CA 92780 <br />'i'NSU'R"ED Cambodian Family _.'~------, <br />1111 East Wakeham Avenue <br />Suite E <br />Santa Ana, CA 92705 <br /> <br />INSURER B <br /> <br />!NSURER C <br /> <br />~~SURER 0 <br />INSURER E: <br /> <br />COVERAGES <br /> <br />THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSUR~D NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDtN <br />ANY REQUIREMENT, TERM OR CONDITION Of ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR <br />MAY Pl:::KTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HFREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF sue, I <br />!=lOLlCIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS <br />l~rt4~ TYPE OF INSURANCE POLICY NUMBER OA TE MMmrl~- DATE" jM'iuDO/YY LIMITS <br />GENERAL.l1A81L1TY PHPJ<074625 03/()9/2004 03/09/2005 EACH OCCURRENCE , 1,000,00 <br /> I X COMMFRcrAL GENERAL LIABIUTY ~s!::_~~I~~~~IICe\ , 300,00 <br /> I .-n CLAIMS MADE 0 OCCUR <br /> MED Ex,," (Any one ~l;:rsOll) , 5 ,()O, <br />A I X 0 deductibl e PERSONAL & ADV INJURY , 1,000,001 <br /> t- GENERI'IL AGGREGATE , 3,000_,001 <br /> rm:N'L AGGREGATf l tMlT APPLIES PER: PRODUCTS. COMPIOP AGG . include. <br /> !Xl UP"O. n <br /> X POLICY JI:CT lOe <br /> AUTOMOBILE liABILITY PHPK074625 03/09/2004 03/09/2005 COMBINED SINGLE LIMIT <br /> t- ANY AUTO (ElIilc.cil..lCnl) . <br /> 1,OOO,OO( <br /> - ALL OWNI:D AUTOS <br /> - BODILY INJURY . <br /> SCHWULED AUTOS (Per person) <br />A X HIRt;D AUTOS <br /> BOQll Y INJURY <br /> X IPereccident) . <br /> NON.QWNEDAUTQS <br /> ~ $0 Deductible _. <br /> PROPERTY DAMAGE S <br /> (Per tlccidenl) <br /> GARAGE UABILITY REVlSEIJ AUTO QNL Y . EA ACCIDENT , <br /> ==J ANY AIITO OTHER THAN lOA ACe s <br /> AUTO ONLY: AGG . <br /> EXCESSJUMBR:HLA L1A51L1TY EACH OCCURRENCE . <br /> =:J OCCUR o CLAIMS MAD!: AGGREGATE . <br /> S <br /> 1 DEDUCTIBLE . <br /> RETENTION . 1/ f I , J. I <br /> WO'KE'SCOMPENSATIONANOC~t2I 'VtAY'.)t\.(dJ2f;P' ((-""- W.TORYlIMITSI I-ER' <br /> EMPLOYERS' LIABILITY - ~ "'.....- ;:;;.--, <br /> ANY PROPRIETORfPARTNER/EXEC TIVE E,L. EACH ACCIDENT I <br /> OFFICERiMEMBER EXCLUDED? . . E.I" DISEASE. EA EMPLOY_I:! . <br /> l1yel!i, d.escribevnder <br /> 5PECIAL PROVJSIQNS below E,L. DISEASE . POLICY LIMIT I <br /> OTHER PHPK074625 03/09/2004 03/09/2005 $1,000,000 Each Claim <br /> buse & Molestation <br />A $3.000,000 Aggregate <br /> SO Deductible <br />E~ESCRt...noN Oo!' ?PERATIONSJ LOCATIONS I Vf:IIICLESJ exCLUSIONSADOED BY ENOORSEMENT / SPECIAL PROVISIONS <br />~mployee Dishonesty liability $200,000 / 0 Ded. <br />Certificate holder is named as additional insured per contract with named insured. <br />Schedule of vehicles and drivers on file. <br />~lO day notic~ of cancella~ion due to non-payment of premium. <br /> <br />CERTIFICATE HOLDER <br /> <br />City of Santa Ana <br />Community Development Agency <br />CDBG-M-2S <br />P.O. Box 1988 <br />Santa Ana, CA 92702 <br /> <br />CANCELLATION <br />SHOULD ANV OF THE ABove DESCRIBI'!D POLICIES Be CANCELLED BEFORE THE <br />EXPIRATION DAn' THEREOF-, THE ISSUING INSURER Will. ~~ MAIL <br />~- DAYS WRITTEN NonCE TO THf CERTIFICATE HOLDER NAMED TO THE LEFT. <br />~K)(~I(I(~II,l(N_)l~J9~!(~KKXXX <br />~1(~~~~~~~J9~~ ~~XXXXXXXXX <br />D REPRESENTATIVE <br /> <br />ACORD 25 (2001/08) FAX: (714)571-1974 <br /> <br /> <br />A.1 A n' <br />