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<br />?`?? °® CERTIFICATE OF LIABILITY INSURANCE OATE(MM,°D/YYYY> <br />02/01/2012 <br /> <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 pollcy(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 1-909-243-8200 CONTACT <br /> NAME: <br />Hays of CnliEOrnia Insurance Services - Ontario PHONE <br />FA% <br /> (g09) 243-8200 <br />: ___.__ _. _.. lac. No7: <br />__._ _ -_ __. _ <br />Empire Toward IV E-MAIL <br />ADDRESS: __ <br />??- <br />3800 G'OIICOnre, Suites 3400 PRODUCER <br />Ontarl0, CA 91764 CUSTOMER ID f!' ,____,__.. __ <br />Xell Paterson INSURER(S) AFFORDING COVERAGE <br />NAIC <br />ff <br /> <br /> <br />INSURED _ <br />..- <br /> <br />INSURER A: COntlnanta_1 Casual ty COmpany _ _ <br />___ <br />_ _ <br />Clinical LnbOratoriaa of San Bernardino, InC- <br /> INSURER B: Transportation Incur ante Co- <br />_- <br /> <br /> <br />P-O- Hox 329 <br />--._ <br />INSURER C: The Hertford insurance Company _ <br />San B <br />di <br />CA 92402 INSURERD: Columbia Casualty Company <br />______- <br />ernar <br />no, <br /> INSURER E - <br /> INSURER F - <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 ANV REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS <br />CERTIFICATE MAY BE ISSUED OR MAV 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 NAVE BEEN REDUCED BY PAID CLAIMS. <br />? ??? <br />INSR <br />LTR <br />TYPE OF INSURANCE ADOL SUER -- <br />POLICY NUMBER MMILDI DY EFF MM/DO EXP <br />LIMITS <br />A GENERAL LIABILT' 2068975201 02/01/1 02/01/13 EACH OCCURRENCE $ 1,000,000 <br /> X <br />.__ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED <br />PREMISES Ea oc_currenceL_ $ 100, 000 <br />_ <br /> ? <br />A <br />? <br />^? <br /> _ CL <br />IMS-MADE l <br />OCCUR MED EXP (Any one person) $ 10, 000 <br /> PERSONAL & ADV INJURY $ 1, 000, 000 <br /> <br /> _ ___._ __ _-._ GENERAL AGGREGATE $ 2,000,000 <br /> GEN'L AGGREGA_ TE LIMIT APPLIES PER: PRODUCTS -COMP/OP AGG $ ExC hided <br /> X POLICY PRO LOC $ <br />A AUT OMOBILE LIABILITY 2068975064 02 O1 1 02 O1 13 COMBINED SINGLE LIMIT <br /> S 1,000,000 <br /> X (Ea accitlent7 <br /> ANY AUTO BODILY INJURY (Per person) <br />- $ <br />_- <br /> ALL OWNED AUTOS <br />BODILY INJURY (Per accitlent) --- ---- <br />$ <br /> SCHEDULED AUTOS _ <br />DAMAGE <br />° <br />$ <br /> X <br />_-_ HIRED AUTOS Par <br />accitlent <br /> X NON-OWNED AUTOS $ <br /> $ <br />H X UMBRELLA LIAR X OCCUR 2068975344 02 /O1/1 02/01/13 EACH OCCURRENCE $ 5, 000, 000 <br /> E%CESS LIAR CLAIMS-MADE AGGREGATE $ 5, 000, 000 <br /> DEDUCTIBLE <br />_ _.- ___. _.____- $ <br />_._____. _. __. <br /> X RETENTION $ 0 $ <br />C WO RKERS COMPENSATION 41AiE4198ZE <br />02/01/1 <br />02/01/13 WC STATU- OTH- <br /> ANO , <br />EMPLOYERS-LIAHILITY i4BY_ ___ __ <br /> \ <br />/N <br />ANY PROPRIETOR/PARTNER/E%ECUTIVE <br />E.L EACH ACCIDENT <br />$ 1, 000, 000 <br /> OFFICER/MEMBER EXCLUDED? ? N / A <br /> (Mantlatory In NH) E.L. DISEASE- EA EMPLOYE <br />'-"'"-- -- $ 1, 000, 000 <br />- - --- <br /> Il yes, tlescribe untler " <br /> DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ 1, 000 , 000 <br />D ro aaa one y 2 -6 7-09- 3- C n mn Mn a a , <br />DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES (Attach ACORO t01, Additional Remarks ScheAUle, If more space Is required) <br />Cartificnta holder 1a Hamad na additional insured ere raapacta Oanarsl Liability only. <br />10 day cancellation notice for non payment of pramium- <br />VCR1IrIl.A1C 1-IVLUCR E -1 @ '\ C:ANI.;CLLAIIVN <br />?7 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />City of Sants Ann ??"' ?/ THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />Dept. of Public Worker -__-_ / ? ? '?? ?? __._, _.______ _ AGGORDAN CE WITH THE POLICY PROVISIONS. <br />-?` I <br />220 S. Dniay Avanua <br />?' ?- l ( - 1 ! ? ? AUTHORIZED REPRESENTATIVE <br />S nntn Ana, G 92703-4334 ' <br />OSA Ke!!y Peterson <br />cj oaaf ©'1988-2009 ACORD CORPORATION. All rights reserved. <br />iaa.vrcu ca tcuun/us) I ne Aa.VRV name aaa logo are regesierea mares or Aa,asrtu <br />25423462 <br />Certificate Delivery by CertiicatesNOw - www.COnlrmNa[.com - 677.669.6600 <br />V + <br />i