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AOC Ro " CERTIFICATE OF LIABILITY INSURANCE DAT 0 511 512 115/261YYYY) <br /> 025 <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 ondorsement(s). <br /> PRODUCER CONTACT Karen Vasquez <br /> 5tateFarm Terry Bradshaw,Agent Lie.#OB80831 arc No Ezt: 714-637-4120 FAAX No: 714-637-4260 <br /> 17871 Santiago Blvd.,Suite 207 E-MAIL . karen@terrybradshaw.org <br /> owl Villa Park,CA 92861 INSURER(S)AFFORDING COVERAGE NAIL# <br /> INSURERA: State Farm General Insurance Company 25151 <br /> INSURED INSURER B: State Farm Mutual Automobile Insurance Company 25178 <br /> Hennessey&Hennessey,LLC INSURERC: <br /> 17602 17th Street,Suite 102-246 INSURER D <br /> Tustin,CA 92780 INSURER E <br /> INSURER F: <br /> COVERAGES CERTIFICATE NUMBER: 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 /> NSR ADD SUB POLICY EFF P LI Y EXP <br /> LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMiDDIYYYY MMIDDlYYYY LIMITS <br /> COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 <br /> �OCCUR DAMAGESORENTED <br /> CLAIMS-MADE <br /> PREMI ES Ea occu a ce $ 300,000 <br /> MED EXP(Any one person) $ 5,000 <br /> A Y Y 92-CZ-W382-6 05/16/2025 05/16/2026 PERSONAL&ADV INJURY $ 1,000,000 <br /> GEN'L AGGREGATE LIMIT AP PLIES P ER: GENERALAGGREGATE g 2,000,000 <br /> PRO- <br /> X POLICY JECT M LOC PRODUCTS-COMPIOPAGG g 2,000,000 <br /> OTHER: 1 $ <br /> AUTOMOBILE LIABILITY 471 7092-E19-75J 05/16/2025 05/16/2026 Eeagcide6tS INGtE JMrr $ 1,000,000 <br /> ANY AUTO BODILY INJURY(Per person) $ <br /> BIx <br /> OWNED SCHEDULED Y Y BODILY INJURY Peraccidenl <br /> AUTOS ONLY AUTOS ( ) $ <br /> HIRED �/ NON-OWNED <br /> AUTOS ONLY /� AUTOS ONLY Per accident $ <br /> v $ <br /> X UMBRELLA LIAR OCCUR EACH OCCURRENCE $ 2,000,000 <br /> A EXCESS LIAR CLAIMS-MADE N N 92-CZ-W386-5 05/16/2025 05/16/2026 AGGREGATE $ 2,000,000 <br /> DED I I RETENTION $ $ <br /> WORKERS COMPENSATION PER OTH- <br /> AND EMPLOYERS'LIABILITY $ <br /> ANY PROPRIETORIPARTNERIEXECUTIVE YIN <br /> F.L.EACH ACCIDENT <br /> OFFICERIMEMBER EXCLUDED? NIA $ <br /> {Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ <br /> Ir yes,describe under <br /> DESCRIPTION OF OPERATIONS below F.L.DISEASE-POLICY LIMIT I $ <br /> DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 1 D1,Additional Remarks Schedule,maybe attached It 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 /> memorandum 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 Digitally signed by <br /> Certificate of Insurance shall provide thirty(30)day prior written notice of cancellation TU Tran Tu Date:2 Nguyen <br /> a[a:2025,Ofi 09 <br /> Nguyen 14:36:46-07'00' <br /> Project Number:A-2021-221-03 <br /> APPROVED <br /> CERTIFICATE HOLDER CANCELLATION By Tu Tran Nguyen of 2:36 pm,Jun 09,2025 <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 ACCORDANCE WITH THE POLICY PROVISIONS. <br /> Risk Management Division AUTHORIZED REPRESENTATIVE <br /> 20 Civic Center Plaza <br /> Santa Ana,CA 927D2 /lCr✓L2lL //L• I/ LGrL <br /> O 1988-2015 ACORD CORPORATION. All rights reserved. <br /> ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD <br /> 1001486 132849.14 04-13-2022 <br />