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?`?oR°® CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/VYYY)
<br />11 10 2011
<br />THIS CERTIFICATE IS ISSUED AS A MATTER OfF??I N?F4OTRMAT?IOQN ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
<br />BELOW C THIS CERT F CATEFOF NSURANCE DLS?S` NO?LQDNS?iT?U?X.?J ?ONORACT BETWEEN O HE?ISSUINGF NSURER(S)TAUTHOR ZED
<br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
<br />'MPORTANT: If the certificate holder is an ADDIT/FO L INSURED, th®? pogcy(fas) must be endorsed. If SUBROGATION IS WAIVED, subject to
<br />le terms and conditions of the policy, certain poli4?-. may require am enelors?r?nent. A statement on this certificate does not confer rights to the
<br />certificate holder in Ifeu of such endorsements
<br />PRODUCER
<br />NAME: t_Y1V Star _ _
<br />Van Gilder Insurance Corp. PNONE ?_- F.4X ---
<br />1515 Wyn)toop, Suite 200 - - A/c No: - -
<br />E-MAIL
<br />Denver CO 80202 ADDRESS_]ChStar?Vg1000m__.._
<br />INSURER(S) AFFORDING COVERAGE NAIC #
<br />_ _ INSURER A :XL ? 7
<br />INSURED INTCON6 INSURER B:T raVOlerS Pr ___ __
<br />9?grty Casual?y___C 5674._.
<br />I nterwest Consulting Group INSURERC:pL-Trav_@lers Indemnit
<br />1076 Lincoln Place ? X--- o£ C _56Q2
<br />BOllldar CO 80302 INSURER D:
<br />INSURER E
<br />INSURER F
<br />COVERAGES CERTIFICATE Nl1M RFRe rn _., -,?? Rcvl Clf'fIJ wlttMnco-
<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 />
<br />LTR
<br />
<br />TYPE OF INSURANCE ADDL
<br />
<br />INSR SUER
<br />
<br />WVD ?
<br />
<br />POLICY NUMBER -??--
<br />POLICY EFF
<br />MM/D D/YYYY
<br />POLICY EXP
<br />MM/DD/YWY - -
<br />? - --
<br />LIMITS
<br />B GENERAL LIABILITY Y Y 6BO?460M6?1 11/14/2011 1/14/2012 EACH OCCURRENCE $2,000,000
<br /> X
<br />COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED
<br />
<br />PREMISES?,Ea occurrence _-?
<br />
<br />$1, 00.0_, 00_0__
<br /> CLAIMS-MADE ? OCCUR MED EXP An one
<br />(,y person)
<br />$10, 000
<br /> PERSONAL SADV INJURY $2, 000, 000
<br /> _. GENERAL AGGREGATE $4,000,000
<br /> __.__
<br /> GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $4,000,000
<br /> POLICY X PRO- LOC $
<br />C AUT OMOBILE LIABILITY Y Y BA?466M429 11/14/2011 1/14/2012 iEa a_ccitlent) x_000 ,_0.00
<br /> X _ ANY AUTO BODILY INJURY (Per person) $
<br />
<br />_ ALL OWNED
<br />AUTOS
<br />__ SCHEDULED
<br />AUTOS BODILY INJURY Per accitlen[
<br />( ) $
<br /> X HIRED AUTOS X NON-OWNED
<br />AUTOS PROPERTY DAMAGE
<br />Per accitlent $
<br />
<br />
<br />B X- UMBRELLA LIAB _ __ OCCUR y Y CUP1330T362 11/14/2011 1/14/2012 EACH OCCURRENCE $l, 000, 000
<br /> EXCESS LIAB CLAIMS-MADE AGGREGATE $1, 000, 000
<br /> DED X RETENTION $10, 000 $
<br />B WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY y VMPJUB1339T93410 11/14/2011 1/14/2012 X WC STATU- OTH-
<br />-
<br /> Y / N
<br />ANY PROPRIETOR/PARTN ER/EXECUTIVE
<br />N
<br />OFFICER/MEMBER
<br />X
<br />
<br />N/A
<br />
<br />E.L. EACH ACCIDENT _ __. _ _ -_
<br />
<br />$1,000,000
<br /> E
<br />CLUDED?
<br />(Mandatory In NH) E.L. DISEASE-EA EMPLOYEE
<br />- $1, 000, 000
<br /> IT yes. describe under ----'--- - --
<br /> DESCRIPTION OF OPERATIONS below E1. DISEASE -POLICY LIMIT $1 , 000, 000
<br />A Professional Liability DPR96952?9 11/14/2011 1/14/2012 Pei Claim $1,000,000
<br /> Claims Made Annual Aggregate 53,000,000
<br /> Retro Date: 6/1/2002
<br />DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES (Attach ACORD t0'I, Additional Remarks Schedule, If more space Is raqulrad)
<br />I£ required by written contract or written agreement, the following provisions apply subject to the policy
<br />terms, Conditions, limitations and exclusions: The Certificate Holder and Owner are included as
<br />Additional Insureds for ongoing and completed operations under General Liability, Automobile Liability and
<br />Umbrella / Excess Liability but only with respect to liability arising out of the Named Insured's work
<br />performed on behalf o£ the certificate holder and owner. This insurance will apply on a primary,
<br />non-contributory basis. A Waiv??13R?, ySUk?r©gato j,<ggs'?}ppl ies for General Liability, Automobile Liability,
<br />See Attached...
<br />-
<br />.
<br />c, -... ,. Iti -.r
<br />I.GK l lr ll..A 1 G nl./L.ucK ?G' GANG'CLLATION
<br />_ - ? SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />?j?7 `- THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />City of Santa And `2) ?„ ACCORDANCE WITH THE POLICY PROVISIONS.
<br />20 Civic Center Paza - Ross Annex (M- )
<br />Santa Ana CA 927[)1 AUTHORIZED REPRESENTATIVE
<br />© 1988-20'10 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2070/05) The ACORD name and logo are registered marks of ACORD
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