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A�® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY)
<br /> 04/11/2025
<br /> THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
<br /> CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
<br /> BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
<br /> REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
<br /> IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed.
<br /> If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on
<br /> this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
<br /> PRODUCER CONTACT Monica Morales
<br /> NAME:
<br /> Lake Insurance Agency PHONE.,
<br /> ONE. Ext: (714)263-3600 A/C,No): (714)263-3600
<br /> 653 South B Street E-MAIL ADDRESS: monica@lakeins.com
<br /> LIC#0747473 INSURER(S)AFFORDING COVERAGE NAIC#
<br /> Tustin CA 92780 INSURER A: Philadelphia Insurance Co. 18058
<br /> INSURED INSURER B: omP State Compensation Insurance Fund 35076
<br /> The Cambodian Family INSURER C:
<br /> 1626 E.4th Street INSURER D:
<br /> INSURER E:
<br /> Santa Ana CA 92701 INSURER F:
<br /> COVERAGES CERTIFICATE NUMBER: 24-26 PKG WC CX REVISION NUMBER:
<br /> THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
<br /> INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
<br /> CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
<br /> EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
<br /> INSR AIJUL 6Ubli POLICY EFF POLICY EXP
<br /> LTR TYPE OF INSURANCE INSD WVD POLICYNUMBER MM/DD/YYYY MM/DD/YYYY LIMITS
<br /> X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
<br /> CLAIMS-MADE Fx_]OCCUR PREMISES Ea occurrence g 100,000
<br /> MED EXP(Any one person) $ 5,000
<br /> A Y Y PHPK2647402023 03/09/2025 03/09/2026 PERSONAL&ADV INJURY $ 1,000,000
<br /> GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 3,000,000
<br /> JECT LOC 1,000,000POLICY ❑ PRO FX
<br /> OTHER: $
<br /> AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000
<br /> Ea accident
<br /> ANY AUTO BODILY INJURY(Per person) $
<br /> A OWNED SCHEDULED PHPK2647402023 03/09/2025 03/0912026 BODILY INJURY(Per accident) S
<br /> AUTOS ONLY AUTOS
<br /> X HIRED NON-OWNED PROPERTY DAMAGE S
<br /> AUTOS ONLY AUTOS ONLY Per accident
<br /> $
<br /> X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 1,000,000
<br /> C EXCESS LIAB CLAIMS-MADE PHUB897848018 03/09/2025 03/09/2026 AGGREGATE $ 1,000,000
<br /> DED I X1 RETENTION S 10,000
<br /> WORKERS COMPENSATION ST/'� ATUTE ER
<br /> OH
<br /> AND EMPLOYERS'LIABILITY Y I N
<br /> ANY PROPRIETORIPARTNER/EXECUTIVE I,000,000
<br /> B OFFICERIMEMBER EXCLUDED? ❑ NIA Y 9064986-2024 06/30/2024 06/30/2025 E.L.EACH ACCIDENT S
<br /> (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S 1,000,000
<br /> If yes,describe under
<br /> DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 1,000.000
<br /> Professional Liability/Sexual or Physical
<br /> Each Professional 1,000,000
<br /> A Abuse PHPK2647402023 03/09/2025 03/09/2026 Aggregate 3,000,000
<br /> Each Abusive 1,000,000
<br /> DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
<br /> City of Santa Ana,officers,agents,employees,and volunteers are named as additionally insured on this policy pursuant to written contract,agreement,or
<br /> emorandum of understanding.Such insurance as is afforded by this policy shall be primary,and any insurance carried by City shall be excess and
<br /> noncontributory with waiver of subrogation.
<br /> Certificate of Insurance shall provide thirty(30)day prior written notice of cancellation Digitally signed
<br /> Tu Tran by Tu Nguyenan APPROVED
<br /> Nguyen
<br /> N U 2C1 Date:2025.04.18
<br /> g y By Tu Tran Nguyen of 3:12 pm,Apr 18,2025
<br /> CERTIFICATE HOLDER CANCELLATION
<br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br /> THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
<br /> City of Santa Ana Attention:Executive Director Community ACCORDANCE WITH THE POLICY PROVISIONS.
<br /> 20 Civic Center Plaza M-25
<br /> AUTHORIZED REPRESENTATIVE
<br /> Santa Ana CA 92701
<br /> ©1988-2015 ACORD CORPORATION. All rights reserved.
<br /> ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
<br />
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