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4. i 178504 Servando Varela dba XV Services Acord Certificate (page I of /) 10/19/2009 12:52:15 PM ACORDTM CERTIFICATE OF LIABILITY INSURANCE DTE A lO/19/2009 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION TECHINSURANCE ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 1301 Central Expy South, Suite 115 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Allen, TX, 75013 r yALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. (800) 668-7020 /' ? INSURERS AFFORDING COVERAGE INSURED INSURER A: The Hartford Servando Varela dba XV Services INSURER B: P.O. Box 28373 INSURER C: Santa Ana, CA 92799 I INSURER D: INSURER E: THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR I POLICY EFFECTIVE POLICY EXPIRATION LTR TYPE OF INSURANCE POLICY NUMBER DAT MM DD Y DATE (MM/DDIYYI LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 I X COMMERCIAL GENER LIABILITY :110/19/2009 DAMAGE TO RENTED $ 300,000 X 46SBMVI9417 10/19/2010 PREMISES (Ea occu rrence _ CLAIMS MADE OCCUR A M(Any o eperson) ' $ 10,000 D EXP - '.,• PERSONAL 8 ADV INJURY I $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER. Ili PRODUCTS - COMP/OPAGG $2,000,000 PRO- X POLICY LOC AUTOMOBILE LIABILITY SII COMBINED SINGLE LIMIT $ 1,000,000 I ANY AUTO i (Ea accident) ALL OWNED AUTOS 46SBMV19417 10/19/2009 10/19/2010 SCHEDULED AUTOS A I BODILY INJURY (Per person) $ X HIRED AUTOS X NON-OWNEDAUTOS BODILY INJURY (Per accident) $ I PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO r-- _ _..... - EA ACC $ OTHER THAN AUTO ONLY:----AGG' $ - - EXCESS LIABILITY '. EACH OCCURRENCE i $ OCCUR CLAIMS MADE AGGREGATE $ il.. DEDUCTIBLE $ $ !. RETENTION $ $ 1. WORKERS COMPENSATION AND or 1` �' WC STATU- ' OTH- EMPLOYERS' LIABILITY ! . TORY LIMITS ! ER _ E.L. EACH ACCIDENT I $... EMPLOYEE $ •'- i 'CC(v E.L. DISEASE POLICY LIMIT $ OTHER �i;prTSey, PROFESSIONAL LIABILITY CLAIMS MADE OCCURRENCE (Ercors &Omissions) �� "' �l AGGREGATE j FIDELITY BOND (Third Party Employee Dishonesty) EACH OCCURRENCE EMPLOYMENT PRACTICES LIABILITY, EACH OCCURRENCE DESCRIPTION OF OPERATIONSILOCATIONS/VEHICLESIEXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Operations pertaining to named inured for certholder, City of Santa Ana and its officers, agents, representatives, volunteers, & employees are additional insured / prim wrd as respects gen'l liab per end'ts CG7158 12/03&CG7253 9/05*30 day NOC expect 1 Oday for nonpayment or premium. CARRIER WILL NOT MODIFY CANCELLATION CLAUSE/NO XX OUT. Note: General Liability Exclusion - Testing or Consulting Errors an Ommissions Form SS05090300 �� ICR: Vl11IVGLLI111Vry SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN City of Santa Ana NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL 20 Civic Center Plaza - Ross Annex (M- ) Santa Ana, CA 92701 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE,-.: ACORD 25-S (7197) © ACORD CORPORATION 1988