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BRODE -3 OP ID: NO <br />'`��� °� CERTIFICATE OF LIABILITY INSURANCE <br />DATE (MM /DD/YYYY) <br />10/01 /12 <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 � 419 -2SS -1020 <br />Hylant Group inc - Toledo <br />8'I 1 Madison Ave - - - 419- 255 -7557 <br />Toledo, OH 43604 - <br />JeannieY. Hylant '- <br />CONTACT <br />NAME _ <br />___ .- <br />PHONE FAX <br />ac No EaL __,_____ -____- 1 (ac No) � ' <br />_ <br />E -MAIL -. -[ — --. <br />ADDRESS: <br />__ _ ______- <br />_____- <br />IN SURER(S) AFFORDING COVERAGE <br />NAIC # <br />wsuRERA:Philadelphia Indemnity Ins Co <br />18058 <br />__. __ <br />INSURED Jay Broderick dba Mad Science <br />of West Orange County <br />3501 W Moore Ave, Ste J <br />_INSURER B :Hartford Ins Co of the Midwest <br />037478 <br />- - - -- - -- -_— <br />INSURER C <br />- - - <br />INSURER D <br />� � - <br />Santa Ana, CA 92704 <br />-_ -_— _ -_ - - _ <br />INSURER E : _. <br />__ _ _._ _ _ _. _ _ _ .. <br />w <br />■ \J -� _ ) Q \ �� O I _ � <br />CJC. 1. �-H <br />__ _. _. ___ <br />_ __- ._ <br />$ `1 $,OO <br />INSURER F <br />$ 1,000,00 <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 />IN UI(:ATE D. 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 />ILTR <br />TYPE OF INSURANCE <br />ADDL <br />R <br />POLICY NUMBER <br />MM DD/YYYV <br />MM DDNYYY <br />LIMITS <br />GENERAL LIABILITY <br />EACH OCCURRENCE <br />$ 1,000,00 <br />A <br />X COMMERCIAL GENERAL LIABILITY <br />CLAIMS -MADE X OCCUR <br />X <br />PHPK927315 <br />1 0/15/12 <br />1 O /15N 3 <br />PREMISES Ea occurrence <br />$ 300.00 <br />-_ <br />MED EXP (Any one person) <br />_ __- ._ <br />$ `1 $,OO <br />pERSONALBADV INJURY <br />$ 1,000,00 <br />A <br />X Abuse /Molestation <br />PHPK927315 <br />10/15/12 <br />10/15/13 <br />_ <br />- - -- - -- <br />GENERAL AGGREGATE <br />$ 2,000,00 <br />_._____.______. _ _ <br />GEN'L AGGREGATE LIMIT APPLIES PER: <br />POLICY PRO LOC <br />PRODUCTS - COMP /OP AGG _ <br />I <br />_$ 2,000,00 <br />� $ 500,00 <br />A8M <br />AUTOMOBILE <br />LIABILITY <br />COMBINED SINGLE LIMIT <br />Ea accitlent) <br />$__ 1 OOO,OO <br />BODILY INJURY (Per person) <br />A <br />ANY AUTO <br />PHPK927315 <br />1 0/15/12 <br />10/15/13 <br />$ <br />ALL OWNED SCHEDULED <br />AUTOS AUTOS <br />$ <br />BODILY INJURY Par accitlent <br />( ) <br />X <br />HIRED AUTOS )( NON -OWNED <br />AUTOS <br />___ _ _ <br />PROPERTY DAMAGE <br />Per accitlanp______ <br />___ __ _ __ ______ _ _ <br />$ _ <br />UMBRELLA LIAB <br />OCCUR <br />EACH OCCURRENCE <br />$ <br />AGGREGATE <br />$ <br />EXCESS LIAB <br />CLAIMS -MADE <br />DED RETENTION $ <br />$ <br />B <br />WORKERS COMPENSATION <br />ANDEMPLOYERS'LIABILITY <br />ANY PROPRIETOR /PARTNER /EXECUTIVE Y/N <br />OFFICER /MEMBER EXCLUDE D4 � <br />(Manda[ory in NH) <br />H yes, describe under <br />DESCRIPTION OF OPE RATIONS below <br />N / A <br />i <br />45WECBH6609 <br />I <br />I <br />10/15/12 <br />10/15/13 <br />WC STATU- OT+I- <br />Y <br />__._._. __ __ _ <br />$____ 1,000,00 <br />-x_ <br />E. L. EACH ACCIDENT <br />_ <br />E.L. DISEASE - EA EMPLOYEE <br />- <br />_$ 1,000,00 <br />--'- <br />$ 1,000,00 <br />- -- - <br />E.L. DISEASE_ - POLICY LIMIT <br />T� T` ©RM <br />DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES (Attach ACORD '10'1, Atltlltlonal Remarks Schedule, It more space Ia requlretl) ppRp ///''' <br />City o£ Santa Ana its o££i cars, agents and employees era included as an .A <br />Additional Insured per Form CG2010. Coverage is on a primary and C\L <br />noncontributory basis except £or gross negligence or wanton and wi11£u1 E STAR e <br />misconduct L \SA pttorr` v <br />C�tY <br />Ass\start <br />l/ <br />Y <br />V CR I Ir' II�A 1 C r1 V LUCK LiANGCLLA 1 IL7N <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 />26 Civic Center Plaza <br />Santa Ana, CA 92701 AUTHORIZED R�EPRE_SOENTATIVE <br />© 1988 -201 O ACORD CORPORATION. All rights reserved. <br />ACORD 25 (201 O /OS) The ACORD name and logo are registered marks of ACORD <br />