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APR -29 -2005 11:06 THE CAMBODIAN FAMILY 714 571 1974 F'.u2''': -011 <br />ACORD CERTIFICATE OF LIABILITY INSURANCE <br />PRODUCER (714)338 -1912 FAX (714)838 -7566 THIS CERTIFICATE 15 138UED AS A MATTER OF <br />Lake Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CE <br />HOLDER. THIS CERTIFICATE DOES NOT AMEND <br />13891 Newport Ave., Suite 29S ALTER THE COVERAGE. AFFORDED BY THE POI <br />Lic 00747473 <br />Tustin, CA 92760 INSURERS AFFORDING COVERAGE <br />._ }NsLmER& Philadelphia Ind. Ins. Co. <br />wsunio 23mliodian FdeiYy — ._.._.. _--- <br />1111 East Wakeham Avenue INSURER IS - <br />Suite E ,4_ Z oq- i(r7 INSURER C _ <br />Santa Ana, CA 92705 A- - an3 NBLEtl11O <br />A- avo,3-- 07S- 60 NCURSR E- - <br />DATE 11119 YYY) <br />D3/07/2005 <br />NFORMATION <br />TIFICATE <br />EXTEND OR <br />CIES BELOW. <br />NAIC N <br />IFD TO THIS INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING <br />OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATF MAY BE ISSUED OR <br />CSCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH <br />:ED BY PAID CLAIMS. <br />Tfl7 "NiM <br />TYPEOPMlUMnC! <br />POLICY NUMBER <br />—W-1 n <br />-.. . <br />aria <br />CEMERAL <br />LIABILITY <br />PHPK130443 <br />03/09/2005 <br />03/09/2006 <br />EAtH DccuRREKE <br />I <br />X <br />COMI MERCIAL GENERAL LWDLLT' <br />REu <br />DAMAE TO m <br />I 100, <br />. . <br />MEDERPIAYbP %Nw l <br />CI ARJR NAnF u ocam <br />t__ , <br />A <br />X <br />_.J <br />0 deductible <br />PERSONAL IAwINJURY <br />1 1,000, <br />1 31000, <br />� <br />- <br />... <br />GENERAL AGCAEWiE <br />GENL <br />AGGREGATE LENT APPLIES PER <br />PRODUCTS- EOMPRWAGG <br />S inclL <br />POLCY� JECT n �OC <br />X <br />AUTOMOWLE <br />-- <br />UAMUTY <br />ANY AUTO <br />PHPK110443 <br />03/09/200S <br />03/09/2006 <br />COMBINED SINOLE LIMIT <br />tEI a6mvI <br />t 1.000, <br />SOOUY IMJUAY <br />Irw Ww) <br />I <br />c <br />X <br />X <br />ALL ONNED AUTOS <br />3CHFDVIEO W706 <br />HIRED AUTO: <br />WA.MJNED AUTOS <br />BODRY INJURY <br />(Pr Arsawl <br />- -- <br />X <br />$O Deductible <br />PROPERTY DAMAGE <br />GARAGE LIABILITY <br />AUTO ONLY - EA ACCIDENT <br />S <br />OTHER THAN EAACC <br />AUTO ONLY Acc <br />i _- <br />t <br />MyAUTO <br />TO <br />FORN4 <br />__......__.. <br />EYCES7NMRRELLjA_LWIPUTY <br />_D.A. <br />EACH OCCURRENCE <br />! <br />OCCUR I -I CLAW MADE <br />.A0OREOATE_ -'" <br />i <br />S <br />t <br />,I <br />DEDUCTIBLE <br />DEDUCTIBLE <br />RVINUON I <br />a <br />Assist <br />I3 C0� <br />I3 Stitt <br />�' <br />nt City Atto <br />neY <br />WORMERS COMPENSATIOMANO <br />EMPLOYERS' LASILDY <br />ANY PROPR4 TOAPAA7NFWtXECUTNE <br />TORY UMrtS --TO <br />E L EACH ACCIDENT <br />1 <br />EL DISEASE. EA EMPLOYE <br />t <br />UFYICERnAEMELRERCLULA07 <br />use i Molestation PHP9110443 03/09/2005 03/09/2006 S1,000,D00 Each Claim <br />A 51,000,000 Aggregate <br />$0 Deductible <br />OESCRPTION Of ERATIO NSILxAnONSIVEHIC730E1t�LIjaIQMS A00FD0 EN00jnd1F rI SPEUAyPRw <br />mployee D_s onesty 1200,000 / De , 00 Pro tssTOna Liabi ity i:5o0,000 Each.00C /3 Mil Aggregate <br />Certificate holder is named as additional insured per contract with named insured. <br />Schedule of vehicles and drivers on file. <br />"Non- Profit Organization " <br />10 day notice of cancellation shall be given in the event of non - payment of premium <br />City of Santa Ana <br />Community Development Agency <br />CDBG -M -25 <br />P.O. BOX 1988 <br />Santa Ana, CA 92702 <br />ACORD2S(20ot10e1 FAX: (714)571 -1974 <br />3NWLD ANY OF THE A8M DESCRIBED POLICIES EE CANCELLED EEFORE THE <br />ER'PMIATION DATE THEREOF, THE nSUING INRUREA WILL K*tXX**% MAIL <br />30 DAYS wmrMN NO" 70 THE CERTIFICATE HOLDER NAMED TO THE LEFT <br />YdBFYK�YYaBB�DtlUIYBIiItAKdihYlalHlX X <br />OACORD CORPORATION 1981 <br />