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ACOCERTIFICATE OF LIABILITY INSURANCE <br />D//2010010) <br />11/21/21R" <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 be endorsed. If SUBROGATION IS WAIVED, subject to <br />the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the <br />certificate holder in lieu of such endorsement(s). <br />PRODUCER <br />Ames and Gough <br />450 Northridge Parkway <br />Suite 102 <br />Atlanta GA 30350 <br />CONTACT Jerry NO Ola <br />NAME: y y <br />acNloExt: (770)552-4225 FAX <br />ADDRIESS:Jnoyola0amesgough.com <br />PRODUCER 00001398 <br />INSURERS AFFORDING COVERAGE NAICB <br />INSURED <br />Kimley-Horn and Associates, Inc. <br />P.O. Box 33068 <br />Raleigh NC 27636 <br />INSURERA:Travelers Indemnity Co. of CT <br />25682 <br />INSURERB:Travelers Indemnity Company <br />25658 <br />INSURERC:Travelers Property Casualty Co. <br />25674 <br />INSURERD:Phoenix Insurance Company <br />25623 <br />INSURER E :Lexin ton Insurance Company <br />_ <br />19437 <br />1 INSURERF:Travelers Prop. Cas. Co America <br />25674 <br />COVERAGES CERTIFICATE NUMBER:*10-11 (Kimley Jessica) 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 CONTRACT OR 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 <br />LTR <br />TYPE OF INSURANCE <br />ADDL <br />SUBR' <br />POLICY NUMBER <br />POLICY EFF <br />MM/DDNYYY <br />POLICY EXP ' LIMITS <br />MM/DDNYYY <br />GENERAL LIABILITY <br />X COMMERCIAL GENERAL LIABILITY <br />_ <br />�.. EACH OCCURRENCE <br />$ 1,000,000 <br />DAMAGE TO RENTED <br />PREMISES Ea occurrence <br />$ 11000, 000 <br />MED EXP (Any one person) <br />$ 10,000 <br />A <br />f CLAIMS -MADE X OCCUR <br />P-630-8193899A-TCT-10 <br />12/1/2010 <br />12/1/2011 <br />PERSONAL & ADV INJURY <br />_ <br />$ 1,000,000 <br />GENERAL AGGREGATE <br />$ 2,000,000 <br />PRODUCTS - COMP/OP AGG <br />$ 1,000,000 <br />GEN'L AGGREGATE LIMIT APPLIES PER: <br />POLICY X PRO X LOC <br />$ <br />B <br />AUTOMOBILE <br />LIABILITY <br />ANY AUTO <br />ALL OWNED AUTOS <br />P-810-5724B497-IND-10 <br />12/1/2010 <br />12/1/2011 <br />COMBINED SINGLE LIMIT <br />(Ea accident) <br />$ 1,000,000 <br />X <br />BODILY INJURY (Per person) <br />$ <br />$ <br />-- <br />BODILY INJURY (Per accident) <br />-X- <br />SCHEDULED AUTOS <br />HIRED AUTOS <br />'I <br />PROPERTY DAMAGE <br />(Per accident) <br />$ <br />X <br />Underinsured motorist BI split <br />- <br />$ <br />NON -OWNED AUTOS <br />Uninsured motorist property <br />$ <br />X <br />UMBRELLA LIAB X OCCUR <br />EACH OCCURRENCE <br />$ 5,000,000 <br />EXCESS LIAB CLAIMS -MADE <br />AGGREGATE <br />. <br />$ 5, OOO, 000 <br />DEDUCTIBLE <br />$ <br />C <br />' X iRETENTION $ 10,000 <br />PSM-CUP-8193B99A-TIL-10 <br />12/1/2010 <br />12/1/2011 <br />$ <br />D <br />F <br />WORKERS COMPENSATION <br />AND EMPLOYERS' LIABILITY Y/N <br />ANY PROPRIETOR/PARTNER/EXECUTIVE <br />OFFICER/MEMBER EXCLUDED? N <br />(Mandatory in NH) <br />I7 yes, describe under <br />DESCRIPTION OF OPERATIONS below <br />PNUB-8193B99A-10 <br />N/A'I <br />PNUB-8193B99A-10 (CA) <br />12/1/2010 <br />12/1/2010 <br />12/1720 11 <br />12/1/2011 <br />WCSTATUTH- <br />X T RY LIMIT- OER <br />E.L. EACH ACCIDENT <br />......... <br />$ 500, 000 <br />— <br />E.L. DISEASE - EA EMPLOYE <br />r---- <br />E.L. DISEASE - POLICY LIMIT <br />- <br />$ 500 000 <br />-------- <br />$ 500,000 <br />E Professional Liability <br />016017332 <br />12/9/2010 <br />12/1/2011 Per Claim $2, 000, 000 <br />Aggregate $2, 000, 000 <br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) <br />Re: McFadden McDonalds. The City of Santa Ana, its officers, employees & volunteers are named as Additional Insureds <br />on the above referenced liability policies with the exception of workers compensation & professional liability. <br />Umbrella Follows Form. <br />114.211 a 07-1111q <br />City of Santa Ana <br />Planning Division <br />P.O. Box 1988 <br />M-20 <br />Santa Ana, CA 92702 <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />AUTHORIZED REPRESENTATIVE <br />tias Ormaza/NOYOLA <br />ACUKU 25 (2009/09) <br />INS025 (200909) <br />© 1988-2009 ACORD CORPORATION. All rights reserved. <br />The ACORD name and logo are registered marks of ACORD <br />