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OP ID: PC <br />'`��'�..°�'� ° CERTIFICATE OF LIABILITY INSURANCE D <br />DATE (MM /DD/YYYY) <br />10/03/11 <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 INSUF���E1.D ES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED <br />REPRESENTATIVE OR PRODUCER, AND /jiH1E ygkgI0?ICDkTEt. <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, ��eertain.policies may require an endorsement A statement on this certificate does not confer rights to the <br />certificate holder in lieu of such endorrment(s): <br />PRODUCER I- , .626- 405 -8031 C <br />CONTACT <br />NAME: _ <br />_ <br />MA' a <br />PRODUCER <br />INSURER(S) AFFORDING COVERAGE N <br />NAIC # <br />INSURED Back to Natives Restoration I <br />INSURER A: NIAC N <br />NIAC <br />INSURER B: Southern Insurance Company 1 <br />19216 <br />INSURER C: <br />INSURER D: <br />INSURER E <br />INSURER F, I <br />COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: <br />L <br />AUTOMOBILE LIABILITY <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 />ILTR TYPE OF INSURANCE PO YE P P <br />POLICY NUMBER MM/DD/YYYY MM /D LIMITS <br />GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 <br />A X COMMERCIAL GENERAL LIABILITY X 201121765NP0 10101/11 10101 /12 PREMISES Ea occurrence $ 500,000 <br />CLAIMS -MADE � OCCUR MED EXP (Any one person) $ 20,00 <br />PERSONAL &ADV INJURY $ 1,000,00 <br />GENERAL AGGREGATE $ 2,000,00 <br />GEN'L AGGREGATE LIMIT APPLIES PER; PRODUCTS - COMP /OP AGO $ 2,000,00 <br />POLICY PRO- <br />COMBINED SINGLE LIMIT $ ,1.000.000 <br />(Ea accident) <br />ANY AUTO BODILY INJURY (Per person) $ <br />ALL OWNED AUTOS BODILY INJURY (Per accident) $ <br />SCHEDULED AUTOS PROPERTY DAMAGE <br />A X HIREDAUTOS 201121765NPO 10/01111 10101112 (Per accident) $ <br />X NON- OWNEDAUTOS $ <br />UMBRELLA LIAB OCCUR EACH OCCURRENCE $ <br />EXCESS LIAR CLAIMS -MADE AGGREGATE $ <br />DEDUCTIBLE $ <br />RETENTION $ _ $ <br />WORKERS COMPENSATION WC STATU- OTH- <br />AND EMPLOYERS' LIABILITY Y T ER <br />B ANY PROPRIETOR/ PARTNER /EXECUTIVE YIN N WS1004552201 10126/10 10126111 E.L. EACH ACCIDENT $ 1.000.00 <br />OFHCER/MEMBER EXCLUDED? N / A <br />'Mantlatory In NH) E.L. DISEASE - EA EMPLOYE $ 1,000,000 <br />If yes, describe under <br />DESCRIPTION OF OPERATIONS below E.L. DIISTEASE♦- POLICY LIMIT $ 1,000,000 <br />AS FO <br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Addid —I Remarks Schedule, it more spa°e Is required) <br />Re: Use of City Premise at 600 E. Memory Lane, Santa Ana, CA 92705. The City <br />of Santa Ana, Its officers, employees, agents and volunteers are named <br />additional insured with respect to the operations of the named insured per <br />the attached CG 2026 endorsement. Such insurance is rime and — i'- `- ` - - - -- - <br />non - contribute er the attached endorsement. <br />primary La.0 rcl 11 st1 Shccil •, <br />CERTIFICATE HOLDER _ <br />The City of Santa Ana <br />20 Civic Center Plaza <br />Santa Ana, CA 92702 <br />CITYSA1 <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 />A(UTHODhR-'EDynREAPRES REPRESENTATIVE <br />© 1988 -2009 ACORD CORPORATION. All rights reserved. <br />ACORD 25 (2009/09) <br />The ACORD name and logo are registered marks of ACORD <br />CERTIFICATE HOLDER _ <br />The City of Santa Ana <br />20 Civic Center Plaza <br />Santa Ana, CA 92702 <br />CITYSA1 <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 />A(UTHODhR-'EDynREAPRES REPRESENTATIVE <br />© 1988 -2009 ACORD CORPORATION. All rights reserved. <br />ACORD 25 (2009/09) <br />The ACORD name and logo are registered marks of ACORD <br />