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<br />ACORDTM CERTIFICATE OF WORKERS' COMPENSATION COVERAGE I DATE (MMlDDIYY) <br /> 2/1/2005 <br /> THIS CERTIFICATE IS ISSUED AS MATTER OF INFORMATION <br />PRODUCER ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE <br /> HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR <br />Driver Alliant Insurance Services, Inc. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. <br />The Transamerica Pyramid <br />600 Montgomery Street, 9th Floor INSURERS AFFORDING COVERAGE <br />San Francisco, CA 94111 <br />INSURED INSURER A: NonProfits' United - Workers' Compensation Group <br /> INSURER B: Grav Insurance Company <br />AIDS Services Foundation of Orange County, Inc. INSURER C Insurance Corporation of Hannover <br />17982 Sky Park Circle, Suite J INSURER D' <br />Irvine, CA 92614 <br /> INSURER E <br /> <br />COVERAGES This Certificate is not intended \0 specify all endorsements, coverages, terms, conditions and exclusions of the policies shown. <br /> <br />THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEO ABOVE FOR THE POLICY PERIOD INDICATED <br />NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY <br />BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND <br />CONDITIONS OF SUCH POLICIES, AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br />INSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS <br />LTR DATE (MMIDD/YY) DATE (MMIDD/YY) <br /> GENERAL LIABILITY EACH OCCURRENCE S <br /> - COMMERCIAL GENERAL LIABILITY FIRE DAMAGE (Anyone fire) S <br /> - ~ CLAIMS MADE D OCCUR MED EXPENSE (Anyone person) S <br /> - PERSONAL & ADV INJURY S <br /> - GENERAL AGGREGATE . <br /> C3E:N'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG . <br /> I nPRa-n <br /> POLICY JECT LOC <br /> AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT . <br /> - ANY AUTO (Eaaccidenl) . <br /> - ALL OWNED AUTOS APPROVED AS TO i \ ~ . c BODiLY INJURY . <br /> - SCHEDULED AUTOS /.L:. :A (Per person} . <br /> - HIRED AUTOS ~/,r j BODILY INJURY . <br /> - - _.... ......,. (Peraccidenl) <br /> NON-OWNED AUTOS LWla t!lt ')i,>. _~ . <br /> - <br /> ASSl'-;tallt llv t\ll<lfll;.'\ PROPERTY DAMAGE $ <br /> - (Peraccidenl) <br /> S <br /> GARAGE LIABILITY AUTO ONLY EA ACCIDENT S <br /> ==1 ANY AUTO OTHER THAN EA ACC . <br /> AUTO ONLY: <br /> AGG . <br /> EXCESS LIABILITY EACH OCCURRENC . <br />-- ~- -- - r=-:-J_",.........-"--""'l:: - ~~ -- - <br /> -- --- -- - - <br />-- -- - <br /> ==1 DEDUCTIBLE $ <br /> RETENTION <br /> WORKERS' COMPENSATION AND I WC STATU. I X 10TH. <br /> EMPLOYERS LIABILITY TORY LIMITS ER <br /> NPU - WCG D01 2/1/2005 1/1/2006 E.L. EACH ACCIDENT .500,000 <br />A <br /> E.L. DISEASE EA EMPLOYEE .500,000 <br /> E L. DISEASE POLICY LIMIT .500,000 <br /> OTHER B = GCR 04-02-221 B - $500,000 X $500,000 <br />B&C Excess Worker's Compensation <br /> C = H35-0402489 2/1/2005 1/1/2006 C = $25,000,000 x <br /> $1,000,000 <br />DESCRIPTION OF OPERATJONSfLOCATIONSNEHICLESIEXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL/PROVISIONS <br />Evidence of Coverage of Workers' Compensation <br /> FEROlPI0'l ;;f'"olO''Jf Pl'.~' ~ <br /> . ., '....... ,I I, _ '.t. _~ .:"1"" <br />CERTIFICATE HOLDER I I ADDITIONAL INSURED; INSURER LETTER: ~ CANCELLATION <br /> SHOULD ANY OF THE ABOVE DESCRiBED POLICIES BE CANCELLED BEFORE THE EXPIRATION <br />City of Santa Ana DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL -"'- DAYS WRITTEN <br />20 Civic Center Plaza NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL <br />P.O. Box 1988 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR <br />Santa Ana, CA 92702 REPRESENTATIVES ./") /'? J /7 <br /> AUTHORIZED REPRESENTATIVE {~ "/11~ ~Y <br /> , <br /> <br />G;\Sharc\csg\doclpcrmIAlpha\NonProfits' UnitedlCel1s oflnsurance\NPU WCG Ce,tll1calc 02{)!05 doc <br />