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DATE (MWDD/YYYY) <br />ACORDTM CERTIFICATE OF LIABILITY INSURANCE 03104/2003 <br />PRODUCER Phone: (BOD) 395 8075 Fax: (858) 519-0822 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION <br />FITNESS AND WELLNESS ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE <br />HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR <br />380 STEVENS AVENUE, SUITE 206 <br />SOLANA BEACH CA 92075 <br />INSURED <br />MARTIN TORRES <br />DBA KARATE DO KIAI <br />12692 RANCHERO WAY <br />GARDEN GROVE CA 92843 <br />INSURERS AFFORDING COVERAGE NAIC # <br />INSURER A: Philadelphia Indemnity Insurance Company — <br />INSURER B: — <br />INSURER C: — <br />INSURER D: _- <br />INSURER E: <br />COVERAGES <br />INSURED NAMED ABOVE FOR THE POLICY PERIOD <br />INDICATED, NOT <br />THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE <br />WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR <br />ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT <br />HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH <br />MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED <br />POLICIES, AGGREGATELIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br />_ <br />INsw ADD' POLICY NUMBER POLICY EFFECTIVE POLICY EXPWATION <br />TYPE OF INSURANCE DATE YMID <br />LIMITS <br />LTR INSR <br />GENERAL LIABILITY PHPK215316 01/24/08 01124/09 <br />EACH OCCURRENCE $ 1,000,000 <br />DAMAGETORENTED 4 100,000 <br />X COMMERCIAL GENERAL LIABILITY <br />PREMISES (E. occumnal _ <br />MED. EXP (Any one person) $ 2,500 <br />CLAIMS MADE [] OCCUR <br />._ <br />PERSONAL BADVINJURY $ 1,000,000 <br />A — <br />GENERAL AGGREGATE 4 3,000,000 <br />PRODUCTS-COMP/OP AGG. $ 3,000,000 <br />GERL AGGREGATE LIMIT APPLIES PER: <br />X POLICY JPEr LOC <br />AUTOMOBILE <br />LIABILITY <br />COMBINED SINGLE LIMIT <br />4 <br />(Ea accident) <br />ANY AUTO <br />BODILY INJURY <br />ALL OWNED AUTOS <br />(Par person) <br />$ <br />SCHEDULED AUTOS <br />-- <br />HIREDAUTOS <br />BODILY INJURY <br />4 <br />(Per accident) <br />NON -OWNED AUTOS <br />- -- <br />- <br />PROPERTY DAMAGE <br />$ <br />Per accident <br />GARAGE LIABILITY <br />AUTO ONLY _EA ACCIDENT <br />OTHER THAN EA ACC <br />ANY AUTO <br />S <br />4 <br />AUTO ONLY: AGG <br />EACH OCCURRENCE <br />EXCESS I UMBRELLA LUIBILITY <br />S <br />AGGREGATE <br />OCCUR CLAIMS MADE <br />_ <br />4 <br />S <br />DEDUCTIBLE <br />RETENTION $ <br />WORKERS COMPENSATION AND <br />�j _ <br />/ <br />F4 <br />STAOTHER <br />Rv LIMITSTLL <br />E.L. EACH ACCIDENT <br />$ <br />EMPLOYERS' LIABILITY <br />(L%...� t� �l� <br />E.L. DISEASE -EA EMPLOYEE <br />4 <br />-- <br />ANYOFF PROPRIETORIDXCLUD (EXECUTIVE <br />RIETOR <br />OFFICERP EXCLUDED? <br />E.L. DISEASE -POLICY LIMIT <br />S <br />Ry.., <br />-: SPECIAL PROVIIII t.1— <br />OTHER: <br />ADDED BY ENDORSEMENT/ <br />SPECIAL PROVISIONS <br />DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLESIEXCLUSIONS <br />insured but only as respects the operations of the named <br />It is understood and agreed that the following entity is added as an additional <br />Additional Insured Endorsement Is Effective: 1124108 <br />insured except that liability resulting from the additional Insureds sole negligence. <br />SEE ATTACHED ADDITIONAL INSURED ENDORSEMENT#CG 20 261185 <br />n. _, , AT,nu <br />The City of Santa Ana, its officers, <br />employees, agents and representatives. <br />P.O. Box 1988 M-23 <br />Santa Ana CA 92702 <br />Attention: <br />ACORD 25 (2001108) Gertmcates ruula <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE <br />EXPIRATION DATE THEREOF. THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS <br />WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE <br />TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, <br />ITS AGENTS OR REPRESENTATIVES. <br />ray E. Frick, CEO <br />.....erg nnoono AT7r1M 101tR <br />