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5-09-200S 1-SSPM FRC"' P_2 <br />AC -QW- CERTIFICATE OF UABIUTY INSURANCE DR <br />rampTDo OR1601M, <br />rwwenl <br />Evazast Insurance services Ino <br />P. 0. Sox 10780 <br />1651 E ro th St., Suite 150 <br />THIS M11F1CATE It;s<IEDAS A MATTER INFORMATION <br />ONLY ANO CONFERS NO RIGHTS UPON THE CERTIFICATE <br />HOLDER. TMS CERTIFICATE DOES NOT ARE EIfTENO OR <br />ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. <br />is.TiTxesv. rx. r.mxelee,rru eerAvillTrrr 30 wrr.�nrr <br />Sacha Ana CA 92701 <br />Phase: 714-569-0800 Fax: 714-569-0807 <br />MSURERS AFFORDING COVERAGE MAICN <br />Casa De Salud r Sy <br />Health Clinin - c a, OCM <br />©oldan Eagle <br />-- <br />wu+eao <br />1421 *d rem*' Ave to B <br />Tustin CA'92700 <br />-'--'� <br />.auPsa c <br />TIE POLICES 0P W49URN40E LISTED BB.Ow NAYS BEENERM vTO THE POSUM NAi®ABOVE FOR TE POLW MOOD 001UTD. NOTN WN4*4 <br />No sEOI.WE mH r.TERLf OR cmanm op Nig cwrmwT OR oTER DOCLA@/f mm RESPECT To MM N TiSmYWATE MAY BE wMM OR <br />WYPFRTN.1. 11P ILW IIIMX'C APPrfiRlrTi i!/ Tif PM x'FAiF,, rRWrrn WWW K 0 W W( Tn N 1 lii 1'fRLLS. PyIY 1 M[Y3[ Mln CfIMMIIfMI/' DF 41(sI <br />P[a1CIF8, AGMECNTE LASTS SHprrN AMY HNA: BEEN R®IAFD BY PAD ClAMM <br />is.TiTxesv. rx. r.mxelee,rru eerAvillTrrr 30 wrr.�nrr <br />— <br />TV/F CI SIiWVICi <br />_ +asY ilribR <br />oYR <br />OOc <br />�i <br />Santa Ana CA 92702 <br />PrrAA�w+rm <br />umxcucvui t 1,000,000 <br />raelai� emrsPe i 100 000 <br />A <br />X caaiB+rx irrlra fu puTv <br />CM054456 <br />07/29/05 <br />07/29/06 <br />cww wa ®acga <br />r.®estrno•.v.+wu $5,000 <br />reraweisAa+suar r 1 000 000 <br />oe+efaneaermc T2, 000, 000 __.. <br />caltAr:lal2i'..rrueT rArua rr» <br />INOeICri-awicv.cc i 1,000,000 <br />RIP <br />AVIOMrwaSMRlry <br />ocxer�c,amxe�iAn i <br />eboM,rr/.twv <br />�1pen0i�� f <br />ilaarmEorwros <br />;oxw�ow*a: <br />iootvsxnr <br />P'R ar`i°°'tt i <br />Iwm wToe <br />xcwp„wtq wYgt <br />TO <br />FORM <br />fAYUw li1BUIY <br />,tN.Vrto <br />_ <br />/ <br />,} <br />]/ <br />/, <br />MJTO OrvLY-GM:CiYxl 9 _ <br />_.__..T.- <br />OlxHi 11W1 FAP4C T J._,_. <br />G <br />wTOGI'.v /,9a f <br />eK/MMMut Wr_lNr <br />CxuMi �•._� cua�ixwx-_.'_ <br />LSU <br />q_,;Ista <br />A SCL[ SYiBC <br />nt 1.Uy Alit) <br />ncv <br />GWW OCCIRFFMCO Y <br />t .ccxcwre <br />I <br />M i <br />adcrBte <br />IiETDITKMI � <br />s <br />WOIIIeN GOileMT10NN0 <br />TORIIAilS CF <br />C� I'AW IGGilYf S <br />wvwwMr <br />.WYN#VPGTORP.WNEREEWINE <br />__...-.. <br />t1. MAW-FAENP.DV6: S <br />OFFlC6M.FMBHfBCALL�®T <br />Sre.TlMf411+W <br />pyw <br />"� <br />F4[�At'fOLCY Un i <br />(1111fa <br />p/CAIIOF V CIEMrnleflOcelOY/MYEyI/ddAW01a MENM9KY6lNf/PfiMLeeNMJe <br />CDvecing operations of the named insured- Certificate holder is named <br />additional insured/4esigaated orgamizatian as per the attached fora. 30 Day <br />NOC for non payment of premi.rm- <br />CERTIFICATE HOLDER CANCELLATION <br />CONiB1N2 <br />eeunAxrarTlaAfvn oMrCNaa rp.roeiweisxauAesowiTseeTRrunx <br />is.TiTxesv. rx. r.mxelee,rru eerAvillTrrr 30 wrr.�nrr <br />Comominity DeVf11,%t t Agfrncy <br />IlenraTowe TE411infR Ni4nrayW4TO TY IST/r. sllRriausem as fe xMat <br />City of Santa Ana <br />20 Civic Center Plaza <br />Santa Ana CA 92702 <br />AAiR° <br />ACORD 23 (2001108) �� CXC0R-�-CORPORATON 1888 <br />