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To: City of Santa Ana From: Jennifer Formaneck 9-23-07 11:30am p. 2 of 9 <br />HCQR~ 4LT4~FffUl"lA~~.~1- ~~Y^{Ui L~E 1 ~''IY+171'u'~11IV4~ ~"„ Dere (mNtld'YYI. <br /> 4/23/2007 <br />Prntlucer Jennifer Formaneck THIS CERTIFICATE IS ISSUED AS AMATTER OF INFORMATION <br /> ONLY ANU CONflRS NO RIGHTS UPON I HE CLN I IF ICAr! HOLUER. <br />Wood Gutmann & Bogart Insurance Brokers THIS CERTIFICATE DOES NOT AMEND. EXTEND OR ALTER THE <br />te 1 OO <br />S <br />15901 R <br />d Hill A COVERAGE AFFORDED BY THE POLICIES BELOW. <br />ve., <br />UI <br />e <br />CA 92780 <br />T <br />i <br />ust <br />n <br />714505.7000 INSURER Zurich US <br />www wgbib.com <br />License No 0679263 <br /> INSURER <br /> <br />InsureN INSURER <br />thleen Forcucci Dance <br />C <br />a <br />Academy, Fullerton INSURER <br />3040 Ma St <br />RLR <br />I <br />Riverside CA 92506 N E <br /> <br />COVERAGES >. <br />THE POLICIES OF INSURANCE LISTED L W HAVE BEEN ISSUED TO THE INSl1RED NAM D ABOVE FOR THE POLICY PERIOD INDICATED. <br />NOTWITHSTANDING ANV REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHIf.H THIS <br />CERTIFICATE MAY BE ISSUED OR MAV PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS S1181ECT TO ALL THE <br />TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br /> POLICY POI ICY <br /> EFFECTIVE EXPIRATION <br />NSR IYP! OF INSURANCE POLICY NUMBER DATE DATE IIMI15 <br />ITR <br /> G FNFRAI I IABILITV EACH OCGIIRRFNGF E <br />A COMMERCIAL GFNFRAI. DAB PPSO42823782 12/4/2006 12/4/2007 DRe nAMAr,F (An one fire x <br /> CI AIMS MADE T~OCCUR MEO E%P An nne hn A 1 <br /> Tenant Leal L PERSONAI FAOV INJURY 5 1 <br /> GFNFRAI ACGRF GATT E <br /> GE NT AGG OMIT APPI IFS PER PRODlIGTS~COMPfOP AGO 8 <br /> PC11CY RDJELT IOC ~ <br /> <br />A A UTOMOBILE l IABII ITV <br />PPSO42823782 <br />12/4/2006 <br />12/4/2007 COMBINED SINf,I F I IMIT <br />1 000 000 <br /> ANY AUTO s <br /> ALI OWNED Al1TO5 BODILY INJURY <br /> SfHFDIII FD AUTOS IPer person) 5 <br /> HIRFO AUTOS BODILY INJURY <br /> NON-0WNFO AlIT05 (Per eccitler[I 4 <br /> PROPERTY OAMAGC <br /> (Per eccltlenp 5 <br /> G ARAGE L IABII ITY AUTO IXJI V - FA ACCIDENT 8 <br /> ANY AlITO OTHER THAN FA ACC $ <br /> AUTOIXJLY ACT, s <br /> FXCFS51 IABII ITY EACH OCCIIRRFNCF 3 <br /> OCCUR ~ CEAIMS MADE ~~ <br />~ <br />f n : AGGREGATE B <br /> ., , i L <br />",l . <br />L..i / t,1 1 f J : 1 <br />~;: <br /> OfIX1C118LE A <br /> RETENTION 3 - $ <br /> WORKERS' COMPENSATION & p - STATUTORY I IMIT THE -. <br /> EMPLOYERS' I IABILITV ~ FL EACH ACCIDENT 5 <br /> ' - <br />~ <br />• EL DISEASE FA FMPI OYFF 5 <br /> Yid+~~ ~Y <br />iaU <br />. EL DISEASE ~POLILY IIMIi 5 <br /> <br />DE RIPTI N F PFRATI N L ATI N EHI LE EX LU I N ADDED BY END R EMENT P IAL PR VI I N <br />City of Santa Ana and their respective officers, emplo ees, agents volunteers and representatives are named as an <br />as an additional insured per attached endorsement CG 20 26 0704. primary wording, GL per form 9S2001 04 99 <br />Waiver applies per form CG 24 04 10 93 <br />his certificate supersedes all others previously issued <br />CERT16{GATE HUL6fR `,;' CANCELLATION <br />+ GL W01Ver SMDIII D ANV OF iHF ABOVE DESCRIBED P01 If, IFS BF CANCFI I FO BEFORE THE <br /> THE ISSUING COMPANY WII I ~~S MAII <br />EXPIRATION DATE THEREOF <br />CI of Santa Ana <br />'r . <br />, <br />3O <br />~ <br /> _ <br />__ <br />DAYS WRITTEN NOTICE TO THE CERTIFICATE H01 DhR NAMED TO THE <br /> LEFT. BUi FAII l1RF TO MAIL SUCH NOTIC.F SHAH IMPOSE NO OBI IGATION <br /> OR LIABII ITV OF ANV KIND UPON THE COMPANY ITS AGENTS OR REPRF~ <br />terPlaza <br />20C <br />i <br />C SENTATIVFS 'iBDaysforNOnfaymentotPremlum <br />IV <br />c <br />en <br />Santa Ana CA 92701 AUTHIX21zE0 <br /> REPRESENTATIVE ~f/~~~~~/J_~~' '~'~,~~~i~[J~~ <br />~ ~e~ <br /> Peer Barsky <br />A~dJfU 2&S ('Ff870 ~ " ~. ~ ~ ~ACQRDCORPORATIQN 9486 ~~ <br />