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-�� BAC KTON -01 DDIAZ AcoRO- CERTIFICATE OF LIABILITY INSURANCE ° 1011/2'1 2 _ 1 0/11 /201 2 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the palicy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the cert ificate holder in lieu of such endorsement(s). PRODUCER I CONTACT NAME Chapman ^' 20" ?J j O PHONE 1 626 405 -8031 FAX. 1 626 405 -0585 a Division of Arthur J. Gallagher 8. Co. ry (A/c, No E :ry (.. _ ) _ {A/c, No): ( ) Insurance Brokers of California, Inc. E MAIL PO Bo. 5455 ADDRESS_ Pasadena, CA 91117 - 0455 r-� _ ^ New York M' I Marine and General Insurance Com is NAIL n INSURER A: Nonprofits' Insurance Alliance of California 011845 INSURED INSURER Comp an Back to Native Restoration :_ INSURER C_: PO BOX 6539 INSURER D Irvine, CA 92612 -6539 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, GENERAL LIABILITY POLICIES_ LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS' EACH OCCURRENCE 5 1,000,OOO INSEXCLUSIONS AND CONDITIONS OF SUCH POLICIES -- -- POLICY EFF POLICY IM - �. LTR TYPE OF INSURANCE INSR,WVD POLICY NUMBER MM/DD /YYYY _{ L (MM /OO /YYYV) LIMITS CLAIMS -MADE X LIABILITY X 201221765NP0 10/1/2012 10/1/2013 k DAMAGE TO 1 PREMISES {Ea occurrence) $ SOO,000 A X COMMERCIAL GENERAL L MED EXP (Any one person) $ 20,000I `.PERSONAL &ADV INJURY $ 1,000,000 OCCUR GENERAL AGGREGATE h $ 2,000,00011 III GE N'L AGGREGATE LIMIT APPLIES PER � I' PRODUCTS - COMP /OP AGG $ 2,000,0001 PRO- POLICY - JECT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT A ANY AUTO '.20122176SNPO 10/1/2012 10/1/2013 BODILY INJURY(P -ae11 „r - 1 AUTOS PROPERTY DAMAGE m 1,000,000 AUTOS NON OVJNED PROacc tlentU INJURY P dr: rt) $ ALL OWNED S(HFJULED X HIRED AUTOS X J UMBRELLA RETENTI CLAIMS -MADE --- DED OCCUR EACH OCCURRENCE S WO AB AGGREGATE $ v AND EMPLOYERS' LIABILITY N $_ - ��ORY LIMITS 1. OTH -'i $ I B ANY PROPRIETOR /PARTNER /EXECUTIVE WC201200000404 10/26/2012 ER OFFR'ER /EMBER EXCLUDED? Y / N N / A' 10/26/2013 - 5 1 r000000� E.L EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE S 1,000,006 Dyes. describe under i EL DISEASE -POLICY LIMIT 1 $ 1,000,000 Mantla[o in NH) ' DESCRIPTION OF OPERATIONS U =!raw T `DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Atlditlonal Remarks Schedule if more space i required) III Re: Use of City Premise at 600 E. Memory Lane, Santa Ana, CA 92705. The City of Santa Ana, its officers, employees, agents and volunteers are namey, X additional insured with respect to the operations of the named insured per the attached CG 2026 endorsement. Such insurance is primary and ibu O %VRl i non - contrtory per the attached endorsement. en 1 I'I A44Rp�� oR�K i Sp, E t p't�oCn�y CERTIFICATE_ _HOLDER CANCELLATION pl�S sari. G� SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BE RE�' The City of Santa Ana THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERE IN 20 Civic Center Plaza ACCORDANCE WITH THE POLICY PROVISIONS. Santa Ana, CA 92702 AUTHORIZED REPRESENTATIVE © 1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD