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12- 13 -'04 12:38 FROM- ALL -CAL INSURANCE 9167840158 T -358 P002/007 F -682 <br />DATE(MMIOOIYYYY) <br />AC CERTIFICATE OF LIABILITY INSURANCE 12/13/2004 <br />COW. <br />��] THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION <br />PRODUCER (916) 784 -9070 <br />/�1L ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE <br />All -Cal Insurance Agency J HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR <br />$01 Riverside Avenue #105 ALTER THE COVERAGE AFFORDED BY THE POLICIES DFLOW. <br />Attn: Beverly <br />n..e..... T T o CA 9567$- INSURERS AFFORDING COVERAGE - NAIL # <br />INSURED <br />California Hispanic Commission on Alcohol <br />and Drug Abuse Prevention <br />2101 Capitol Avenue <br />t^A 95816- <br />luvm .V.o <br />THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY <br />REQUIREMENT, TERM OR CONDITION P L CONTRACT OTHER DOCUMENT RESPECT O CERTIFICATE MAY BE ISSUED OR MAY <br />ANPOI IES DESSCRIBEDHEREINISSUBJECT TO ALL TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES <br />AGGREGATE <br />IMR <br />LTR INS <br />ADDL <br />LIMITS SHOWN MAY HAVE BEEN <br />TYPE OFIN&URANCE <br />REDUCED BY PAID GLAIMS. <br />POLICY NUMBER <br />POLICY EFFECTIVE <br />DATE ODIYY) <br />/ / <br />LIMITS <br />CH OCCURRENCE <br />& 1, 000, OC <br />MAGE ;O RENTED <br />EMI E Fa acalRende <br />ED EXF AA one arso n) <br />& 50, OL <br />A <br />A <br />X <br />X <br />GENERAL LIABILITY <br />X COMMERCIALGENERALLIABILITY <br />cvms MADE ❑X DOCUft <br />X PROFESSIONAL LIAR. <br />2004 -03026 <br />11/18/2004 <br />/ / <br />7W1,000,0C <br />i 5, OC <br />R60NAL &ADV INJURY <br />i 1,000, OC <br />ENERALAGGREGATE <br />f 2,000, OC <br />X <br />BMPLOXE}' 8EN18IT6 <br />ODUCTS- COMP/OP AGG <br />f 2, 000, OC <br />GEIYLAGGRI!r7,LIppMIT APPLIESPER: <br />X POLICY JECT LOG <br />AUTOMOBILE LIABILITY <br />IMBROPER SEXUAL COW <br />COMBINED SINGLE LIMIT (ea <br />(Ea actidant) <br />1,000,OC <br />1, ODD, OC <br />ANY AUTO <br />ALL OWNED AUTOS <br />200403026 <br />11/16/2004 <br />11/16/2005 <br />(PU Pelson) <br />(Fwtp Iom) <br />f <br />X SCHEDULEDAUTOS <br />X HIRED AUTOS <br />., / <br />/ / <br />EDGILY INJURY <br />(Pe OdaM) <br />& <br />X NO1,LOV,NGDAUT06 <br />• COMB OED: $250 <br />f1CJ <br />p1 <br />/ /'` <br />/ / <br />PROPERTY DAMAGE <br />(Pwl dmt) <br />f <br />• COLLISION DED: $500 <br />GARAGE LIABILITY <br />ANY AUTO <br />- <br />_..� y <br />'. 1 <br />SAO <br />�(' ASP `� GM <br />Cj q `1 <br />ti� OCl e�/ <br />'UTo ONLY- EAACCIDEPIT <br />S <br />OW.'R LAN EA ACC <br />AUTO ONLY: <br />AGG <br />9 <br />i <br />X OCCUR ❑ CLAIMS MADE <br />T EX,ESSNMBREUA LIABILITY <br />I <br />/ / <br />EACH OCCURRENCE <br />f 4, 000, OC <br />AGGREGATE <br />i 4,000, OC <br />3 <br />DEDUCTIBLE <br />X RETENTION &10,000 <br />WORKERS COMPENSATION AND <br />2004- 03026MM <br />, <br />11/18/2004 <br />/ / <br />11/10/2005 <br />/ / <br />U tT6 R <br />i <br />EMPLOYERS' UAINLUY <br />E.L. EACH ACCIDENT <br />& <br />ANY PROPRIEfOR(PARTNERIE)(ECUTIVE <br />OFFICER/MEMBERFXCLUGED? <br />/ / <br />/ / <br />E.L. DISEASE -EA EMPLOYE <br />i <br />E.L DISEASE- POLICY LIM17 & <br />LIMIT $100, OC <br />DEDUCTION $5C <br />LIMT $ 1,000,00 <br />B <br />A <br />It yes, decodoe UWK <br />SPECIAL PROVISIONS Eabw <br />OTHER EMPLOYEE DISHONESTY <br />FORGERY /ALTERATION <br />DIRECTORS G OFFICERS <br />CWB 000 2271 02 03026 <br />CM 000 2271 02 03026 <br />2004- 03026DO <br />11/18/2004 <br />11/18/2004 <br />11/1$/2004 <br />11/18/2005 <br />11/18/2005 <br />11/18/2005 <br />DEBCRIPRON OF OPERATION SILOCA.TONSNENICLESIEXCLUMONS ADDED BY EN130MEMENTISPEGIAL PROVISIONS <br />THE CITY OF SANTA ANA, ITS OFFICERS, AGENTS, OFFICYALS, EMPLOYEES, AM vOLuNTEERS ARE NAMED AS ADDITIONAL INSURED AS <br />FUNDING SOURCE TO THE INSURED. FORM CG 2026 APPLIES. <br />CERTIFICATE HOLDER ' ptn '«Lm5w.� <br />SHOULD ANY OF THE ABOVE DESCRIBED POLI0IE6 BE CANCELLED BEFORE THE <br />ANABELL BATES EXPIRATION DATE THEREOF, THE ISSUING INSURER HALL XXXK PAIL <br />30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, W <br />CITY OF SANTA ANA 1(ffiEi( Iii@ QXMi( XrK14XDfX25%YNY1tMAPflN61f1flfe <br />p.o. BOX 1988 M -73 X <br />20 CIVIC CENTER PLAZA AUYHOBIYED RnPREBENTATIVE <br />RD 25 (2001108) [/ m ACORD <br />INS025 (OAOB).05 ELECTRONIC LASER FORMS, I (OM327-0645 <br />Pais ) 1 <br />