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ATTACHMENT "C" <br />Sample Certificate of Insurance <br />ACORD? CERTIFICATE OF LIABILITY INSURANCE UAT£(MM1D <br /> <br /> <br />PRODUCER 01131/2001 <br />01 <br /> THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION <br /> ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE <br /> HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR <br /> ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. <br /> INSURERS AFFORDING COVERAGE <br />INSURED <br /> INSURER A. <br /> INSURER B <br /> INSURER C <br /> ( INSURERD _ <br /> INSURER E. ----- <br />THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING <br />ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT <br />WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR <br />MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS <br />EXCLUSIONS A <br />P <br /> <br />OLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. , <br />ND CONDITIO NS OF SUCH <br />TYPE OF INSURANCE ! POLICY NUMBER p VC <br />E POLICY EXPIRATION ' ------ -- <br />F <br /> <br />DATE I <br />7M <br />IDD/YY LIMITS <br />GENERAL LIABILITY X111111111 <br />r -; 10110112001 <br />X <br />COMMERCIAL GENERAL LIABILITY <br />.. <br />01/0112002 <br />?.EACHOCCURRENCE 15 <br />1,000,000 <br /> <br />..._ , , <br />_ I CLAAASMADE X OCCUR j I FIRE OAIJwGE (Any one fire) I C <br /> <br />-_- - 50,000 <br /> i MED EXP (Any aw Paron) 5.000 <br />- <br />-..? ..._ ' _. ' _._. ? 1'ERSOMAL 8 AO!' INJURY <br />. <br />s 1.000.000 <br />i ,."_ ._ ----- - <br />Jt AGGREGATE U1,417 ' APPLIES'?FR <br />! ? <br />1 GENERAL AGGREGATE 2,000,000 <br />- <br />. <br />; , <br />PRO <br />i <br />POLICY <br />F__ PRODUCTS - COMP OPAGG ' S 2,000,000 <br />; <br />i LOC <br />JIFCT <br />AUTOMOBILE LIABILITY - j X222222222 i 01/01/2001 01/0112002 <br />X ! ANY AUTG. i <br />I COMBINED SINGLE LIMIT <br />(Ea acodenl) 1,000,000 <br />ALL 6V.'NEC AUTOS ? - -- <br />l SCHLOULED AUTOS ! t9PbpDILi nNR1 G <br />-.. J HIRED AUTOS <br />. <br /> <br />NON-OWNED AU! OS BODILY INJURY <br /> <br />( S <br />(Per Wddenl ) <br />.__.._.._. .. -.._. _ ' <br />- SEE ATTACHED ADD PROPERTY DAMAGE <br />(P`"a`Gd°°'' <br />ITIONAL <br />GaaacE LwB1urY <br /> <br />ANY AUTO INSURED ENDORSEMENT AUTO ONLY - EA ACCIDCNT $ <br />EAA <br />OTH <br />N <br />- <br />- - <br /> <br /> <br />I CG <br />S <br />; <br />ER THA <br />1 <br />- i --- <br /> <br />-- <br /> AUTO ONLX: AGG I S <br />EXCESS LIABILITY _ <br />OCCUR r „ EACH OCCURRENCE 15 <br />L-IMSMADE COVERAGES DEPEND O <br />' <br />-- - <br /> <br />----- <br />N TYPE AGGREGA <br />7E <br /> <br />I ; I <br />DEDUCT BLE OF AGREEMENT/CONTRACT -- <br /> <br />RETENTION S <br />s <br />WORKERS COMPENSATION AND j XXX333333333 <br />EMPLOYERS'LIABILITY 01!0112001 01!01!2002 .; X vaG sraru- 0TH <br />-I <br /> <br />i <br />` E. L. EACH ACCIDENT S 1,000,000 <br />I i El. DISEASE - EA EMPLOYE S 1,000,000 <br /> <br />'-'--"- <br />OTHER <br />11 PL444444 <br />! <br />01101/2001 <br />E 1, DISEASE -POUCY LIMIT ' S <br />1,000,000 <br />Professional Liability <br />i 01/0112002 Each Occurrence 1,000,000 <br />DESCRIPTION OF OPERATIONSAOCATIONSNEHICLESIEXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS <br />Certificate Holder is additional insured per attached. <br />Project No. <br />CFRTIFIneTF unl nCO __---- <br />BOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EX <br />PIRATION <br />City of Santa Ana SSUING INSURER WILLS MAIL _30_ DAYS WRITTEN <br />20 Civic Center Plaza - Ross Annex {M- FICATE HOLDER NAMED TO THE LEFT <br />Santa Ana, CA 92701 <br />1::: <br />AUTHORIZED REPRESENTATIVE <br />ACORD 25-S (7197) 0ACORD CORPORATION I aRR