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A'CORD CERTIFICATE OF LIABILITY INSURANCE OPID cs DATE(MM/DDlYYYY) <br />ALEVI-2 11/14/08 <br />PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION <br />Kosmos Insurance - COCIA ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE <br />License #OE83671 HOLDER. THIS CERTIFICATE DOES NOT AMEND <br />EXTEND OR <br />1913 E . 17th Street, Suite 213 , <br />ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. <br />Santa Ana CA 92705 <br />Phone: 714-972-0950 Fax:714-541-5597 INSURERS AFFORDING COVERAGE NAIC # <br />INSURED INSURER A Oregon Mutual Ins . Co . <br /> wsuRERe Oak River Insurance Co 34630 <br />John G AleVl ZOS D . O . IIIC . INSURER C <br />800 N. Tustin Ave. , Suite A <br /> <br />Santa Ana CA 92705 wsuRERD <br /> <br />r~~ irei w `. ~~. 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 WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR <br />MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS <br />EXCLUSIONS AND CONDITIONS OF SUCH <br />, <br />POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br /> <br />LTR <br />NS <br />TYPE OF INSURANCE <br />POLICY NUMBER OL F C IVE <br />PATE MMIDDM' LICY PIRA I N <br />DATE MM/DD <br />LIMBS <br /> GENERAL LIABILITY EACH OCCURRENCE $ 2000000 <br />A X X COMMERCIAL GENERALUABILITY BSP704154 08/12/08 08/12/09 PREMISES (Eaoccurence) $ 100000 <br /> CLAIMS MADE ~ OCCUR MED EXP (Any one person) $]000 <br /> PERSONAL&ADV INJURY $200QQQQ <br /> X Non Owned $2 , OOO , GENERAL AGGREGATE $ 4000000 <br /> GEN'LAGGREGATELIMITAPPLIESPER. PRODUCTS-COMPlOPAGG $ 3000000 <br /> POLICY JECT LOC <br /> AUT OMOBILE LIABILITY <br /> COMBINED SINGLE LIMIT $ <br /> AtJY AUTO (Ea accident] <br /> ~ <br /> ALL OWNED AUTOS ~ ~ }~.,, iW ` <br /> <br />SCHEDULED AUTOS <br />~~~ <br />"'~ ~ BODILY INJURY <br />(Per person} $ <br /> HIRED AUTOS ~~ <br /> <br /> <br />NON-OWNED AUTOS V~ <br />V <br />A prR <br />l'~11 / <br /> <br />~ / <br />/ <br />BODILY INJURY <br />(Per accdent} <br /> <br />$ <br /> ~ ~~v <br /> --- S ~Z <br />' <br />-•• PROPERTY DAMAGE $ <br /> ~~Y ~<•.', • <br />~. (Per accident) <br /> GARAGE LIABILTIY ~au 11,V AUTO ONLY - EA ACCIDENT $ <br /> ANY AUTO ~: 1 OTHER THAN EA ACC $ <br /> AUTO ONLY: qGG $ <br /> EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ <br /> <br /> OCCUR ~ CLAIMS MADE AGGREGATE $ <br /> <br /> DEDUCTIBLE <br /> RETENTION $ <br /> $ <br /> WORKERS COMPENSATION AND W S A 11 - <br /> EMPLOYERS' LIABILITY TORY LIMITS ER <br />B ANY PROPRIETOR/PARTNERlEXECUTIVE <br />OFFICER/MEMBEREXC 2200021717-081 lO/O1/OS ZO/O1/O9 E.LEACHACCIDENT $ ZOOOOOO <br /> LUDED? <br />If yes, describe under E.L. DISEASE-EA EMPLOYEE $ ZOOOOOO <br /> SPECIAL PROVISIONS below EL.DISEASE-POLICY LIMIT $~,000OOO <br /> OTHER <br />DESCRIPTION OF OPERATIONS /LOCATIONS !VEHICLES /EXCLUSIONS ADDED BY ENDORSEMENT !SPECIAL PROVISIONS <br />Certificate Holder is named as Additional Insured but only as respects to <br />agreement with the City of Santa Aaa. <br />*except 10 days notice of cancelation if due to non-payment of premium <br />f CDTI L'1/"A TC LIA1 11CG _ _ _._-_ _ _-_ _ <br />CITOFI7 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION <br />DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 3O * DAYS WRITTEN <br />NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL <br />City of Santa Ana <br />PO BOX 19 8 8M-41 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, TFS AGENTS OR <br />santa Ana CA 92702 REPRESENTATIVES. <br />ACORD 25 {2001108) ©ACORD CORPORATION 19E <br />