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<br />. , DATE (MM/OOIYYVY) <br /> ACORD. CERTIFICATE OF LIABILITY INSURANCE OP 10 J9 <br /> THECA-1 06/24/04 <br />PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION <br />Chapman & Associates ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE <br />License #0522024 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR <br />P. O. Box 5455 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. <br />Pasadena CA 91117-0455 <br />Phone: 626-405-8031 Fax:626-405-0585 INSURERS AFFORDING COVERAGE NAIC# <br />--~._--_._-_.-~-- <br />INSURED INSURER A: State Compensation In. J'und <br /> -- ---"~- <br /> INSURER B: <br /> The Cambodian Family INSURER c: <br /> 1111 E. Wakeham Ave., Suite E INSURER 0: <br /> Santa Ana CA 92705 <br /> INSURER E: <br /> <br />COVERAGES <br /> <br />THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING <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 />LTR NSR TYPE OF INSURANCE POLICY NUMBER PDA';!~ 'iJ'~DEn,w}E P~k~l.oll~~b~~N LIMITS <br /> GENERAL LIABILITY EACH OCCURRENCE $ <br /> f-- PREMISES (E~~~~~~nce) .___.n__ <br /> COMMERCIAL GENERAL LIABILITY $ <br /> I CLAIMS MADE D OCCUR MED EXP (Anyone person) $ <br /> -.------ <br /> I- I PERSONAL & ADV INJURY $ <br /> -~---~-- -~----_._- - ---'- <br />I GENERAL AGGREGATE . <br /> .- <br /> GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ <br /> II ,nPRO' n <br /> POLICY JECT LOC <br /> ~OMOBILE LIABILITY COMBINED SINGLE LIMIT $ <br /> ANY AUTO (Eaaccidenl) <br /> - ,'1JI <br /> ALL OWNED AUTOS VO\' BODILY INJURY <br /> - 0 $ <br /> SCHEDULED AUTOS /'.S ~ (Per person) <br /> - -- <br /> - HIRED AUTOS O'-l~D BODILY INJURY <br /> fi;~// $ <br /> NON-QWNED AUTOS /'.'?'?~ ~ (Peraccidenl) <br /> -- <br /> 1'""1 PROPERTY DAMAGE . <br /> r;?--..:..\\\.\ J '"' t<\c" (Per accident) <br /> <\n' <br /> GARAGE LIABILITY ~. aU\<- . C\ ~ AUTO ONLY. EA ACCIDENT $ <br /> '" . <br /> =1 ANY AUTO S\'3-\.\"- EA ACC $ <br /> p...'6~\ OTHER THAN <br /> AUTO ONL V: AGG $ <br /> EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ <br /> =:J OCCUR D CLAIMS MADE AGGREGATE . <br />, $ <br /> =1 ~EDUCTIBLE . <br /> f-- <br /> RETENTION . $ <br /> WORKERS COMPENSATION AND X I TOR/LIMITS I IV~" <br /> EMPLOYERS' LIABILITY <br />A ANY PROPRIETOR/PARTNER/EXECUTIVE 1696570 06/30/03 06/30/04 E.l. EACH ACCIDENT $1000000 <br /> -.---.,. <br /> OFFICER/MEMBER EXCLUDED? El. DISEASE. EA EMPLOYEF.: .!..1000000___ <br /> If yes, describe under -- <br /> SPECIAL PROVISIONS below E.l. DISEASE. POLICY LIMIT $1000000 <br /> OTHER <br />DESCRIPTION OF OPERATIONS fLOCATIONS {VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT {SPECIAL PROVISIONS <br />Evidence of Coverage <br /> <br />CERTIFICATE HOLDER <br /> <br />CANCELLATION <br /> <br />SANTANA <br /> <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION <br />DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL ~ DAYS WRITTEN <br />NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL <br />IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR <br />REPRESENTATIVES. <br />AUT ED REPRE <br /> <br />City of Santa Ana <br />P.O. Box 1988 <br />Santa Ana CA 92702 <br /> <br /> <br />@ACORD CORPORATION 1988 <br /> <br />ACORD 25 (2001/08) <br />