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-��1 BACKTON -01 PATRA4 <br />ACO/�O" DArE �MM /DD/vwvl <br />CERTIFICATE OF LIABILITY INSURANCE 1o/s/2o12 <br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTI FICATEHOLDER. 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 INSU RER(S), AUTHORIZED <br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. <br />I IMPORTANT: If [he 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 />I PRODUCER CONTACT <br />'Chapman rlAi °ae -- 1 626 405 -8031 - -- FAZ -- -- - <br />a Division of Arthur J. Gallagher 8 Co. lA /a, Nps.E:1� ( ) � (A /o, No) 1 (626) 405 -0585 <br />Insurance Brokers of California, Inc. E -Mali - -- <br />PO BOX 5455 ADDRESS: _ -. _. - <br />Pasadena, CA 91197 -0455 INSURERS) AFFORDING COVERAGE I NAIC # <br />wsuRER A :Nonprofits' Insurance Alliance of California 011845 <br />wsuRED INSURER B New York Marine and General Insurance Company 16608 <br />Back to Native Restoration wsuRER c <br />PO BOX 6539 INSURER D ' <br />Irvine, CA 9261 2 -6539 I INSURER E - - � I - <br />�. <br />COVERAGES <br />_... <br />CERTIFICATE <br />- ____.. <br />-. -__. __.u- ......��.�. <br />NUMBER: <br />. <br />REVISION NUMBER: <br />THIS <br />IS TO CERTIFY THAT THE POLICIES <br />OF <br />INSURANCE <br />LISTED BELOWHAVE BEEN <br />ISSUED <br />TO THE INSURED <br />_ <br />NAMED ABOVE FOR THE POLICY PERIOD , <br />INDICATED. <br />NOTWITHSTANDING ANY REQUIREMENT, <br />TERM OR CONDITION OF ANY <br />CONTRACT <br />OR OTHER <br />DOCUMENT WITH RESPECT TO WHICH THIS <br />CERTIFICATE <br />MAY BE ISSUED OR MAY <br />PERTAIN, <br />THE INSURANCE AFFORDED BY <br />THE POLICIES <br />DESCRIBED <br />HEREIN IS SUBJECT TO ALL THE TERMS, <br />EXCLUSIONS <br />AND CONDITIONS OF SUCH <br />POLICIE <br />IMITS SHOWN MAY HAVE BEEN <br />B <br />�INSR <br />I LTR <br />- - <br />j TYPE OF INSURANCE _ <br />ADDL <br />Iry$R <br />SUER <br />WVD <br />� <br />- <br />-- POLICY NUMBER <br />MM /DD/YYW ) <br />� OL GVD <br />I {MM C yWj <br />-- <br />LIMIT55 <br />GENERAL LIABILITY <br />I <br />EACH OCCURRENCE 1,000,000 <br />A <br />X COMMERCIAL GENERAL LlIAB( LITV <br />X <br />!201 221 76 5N PO <br />10/1/2012 <br />10N /2013 <br />DAMAGE 70RENTE6 - - - <br />I $ 500,000 <br />I <br />__PREMISES (Ea occurrence) _. <br />CLAIMS -MADE X OCCUR <br />I <br />I <br />MED EXP An one n) $ 20,000 <br />� <br />4 <br />PERSONAL 8 ADV INJURY 1 $ 1,000,000 <br />� <br />GENERAL(AGGREGATE <br />- f $ 2,000,000( <br />GE AGGREGATE LIMIT APPLIES PER <br />i <br />PRODUCTS /OP AGG $ 2,000,OOOiI <br />� <br />J POLICY i i JECT- LOC _ <br />� _I <br />- <br />_COMP <br />' <br />I AUT'L <br />OMOBILE LIABILITY <br />COMBINED SINGLE LIMIT <br />� <br />Ea accltlent <br />$ 1.000.000 <br />��I <br />� ANY AUTO <br />'I <br />20122176$NPO <br />' 10/1/2012 <br />1 ON /2013 <br />( person) <br />$ - -�1 <br />' <br />_ <br />ALL OWNED SCHEDULED <br />it <br />i <br />- <br />AUTOS AUTOS <br />I <br />I <br />(Per accitlenry <br />$ <br />_.. <br />NON -OWNED <br />X HIRED AUTOS X gUTOS <br />' <br />I <br />j (ROPERTY DAMAGE <br />Per accltlent <br />- <br />g <br />- <br />1' <br />I <br />' <br />UMBRELLA LIAB <br />I <br />- <br />EACH OCCURRENCE <br />5 <br />{_EXCESS LIAB 1 l OLAIMS -MADE( <br />- <br />AGGREGATE <br />g ' <br />' I <br />DED RETENTION $ <br />- _- __ - <br />_..... __ <br />$ <br />_� <br />WO RKERS COMPENSATION - - <br />_.- _ _. - -- - -- � <br />- - _- <br />F - - -- - <br />WC STATU OTH i <br />B <br />i AND EMPLOYERS' LIABILITY V / N <br />_ TORY LIMITS _ER _ <br />PROPRIETOR /PARTNER /EXECUTIVE <br />WC201100000404 <br />10/26/2011 <br />10/26/2012 <br />E L EACH ACCIDENT $ 1,000,OOO <br />I <br />OFFICER /MEMBER EXCLUDED? � J I <br />N/ A <br />i <br />(Myantla[ory in NH) - � <br />I <br />EL DISEASE - EA EMPLOYEE 5 1,000,000 <br />DESCRIPTION OF OPERATIONS <br />below _ <br />- <br />- <br />-- _ - _ <br />- -. <br />EL DISEASE - POgLIgCV LgIMIT $ 1,000,000 <br />A (ABUSE <br />;201221765NP0 <br />I <br />10/1/2012 <br />i <br />10H /2013 <br />Occurence /A re ate 1,000,0001 <br />DESCRIPTION <br />OF OPERATIONS /LOCATIONS /VEHICLES <br />(Attach <br />ACORD 101, Adtlitional R¢marMS Sc hetlule, <br />i! more spat¢ is <br />requiretl) <br />' <br />Re: <br />Use of City Premise at 600 E. Memory Lane, <br />Santa <br />Ana, CA 92705. The City of Santa <br />Ana, its officers, <br />employees, <br />agents and volunteers are named '� <br />additional <br />insured with respect to the operations <br />contributory per the attached endorsement. <br />of the <br />named insured per the attached <br />CG 2026 endorsement. <br />Such <br />insurance is primary .w �I I <br />rt <br />(non- <br />F��` <br />STD <br />Ap4R�V£� A <br />CERTIFICATE HOLDER CANCELLATION t- �����,\ yOA 'fOY ney^ - - <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CA NCELLE BE�ORE <br />The Clty of Santa Ana THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELI ERED IN '. <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />20 Civic Center Plaza <br />Santa Ana, CA 92702 j <br />AUTHO(/RI/Z^ /E� /D REy /P /nvRESENTATIVE <br />V ��'� I. <br />© 1988 -2010 ACORD CORPORATION. All rights reserved. <br />ACORD 25 (2010/0 S) The ACORD name and logo are registered marks of ACORD <br />