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AC"R�0 <br />CERTIFICATE OF LIABILITY INSURANCE <br />DATE (MM/DD <br />011 <br />11/10/2011 <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(les) 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 <br />Grayling Insurance Brokerage <br />450 Northridge Parkway <br />Suite 1.02 <br />Atlanta GA 30350 <br />CONTACT Jerr NO Ola <br />NAME: Y Y <br />PHONE (770) 552-4225 NO e: (866)550-4082 <br />E-MAIL .jarry.noyo1a@grBy1ing.com <br />INSURERS AFFORDING COVERAGE NAIC0 <br />INSURERA:Travelers Prop. Cas. Cc America 25674 <br />INSURED <br />Kimley-Horn and Associates, Inc. <br />P.O. Box 33068 <br />Raleigh NC 276.36 <br />INSURERB:Travelers Indemnity Company 25682 <br />INSURER c:Lexin ton Insurance Company 19437 <br />INSURER D: <br />INSURER E: <br />INSURER F: <br />COVERAGES CERTIFICATE NUMBER:11-12 (Kimley Janice) 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 />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 />INSRPOLICY <br />LFR <br />TYPE OF INSURANCE <br />ADDL <br />SUER <br />POLICY NUMBER <br />EFF <br />MMIDDNYYY) <br />POLICY EXP <br />: (MM/DDIYYYY1 <br />LIMITS <br />Santa Ana, CA 92702 <br />GENERAL LIABILITY <br />Matias Ormaza/JERRY <br />EACH OCCURRENCE $ 1,000,000 <br />A <br />X COMMERCIAL GENERAL L1ABlLITY <br />CLAIMS -MADE F OCCUR <br />-630-8193 A -TIL -11 <br />PRO D AS <br />2/]/2011 <br />TO FORM <br />2/1J2012 <br />DAMAGE T RENTED 1,000,000 <br />PREMISES Ea occuvence $ <br />MED EXP (Any one person) S 10,000 <br />PERSONAL &ADV INJURY S 1,000,000 <br />GENERAL AGGREGATE S 2,000,000 <br />GEN'L AGGREGATE LIMIT APPLIES PER: <br />PRODUCTS - COMPlOPAGG $ 1,000,000 <br />POLICY X PRO X LOC <br />( I <br />$ <br />AUTOMOBILE <br />LIABILITY <br />Y O. <br />ODGE <br />COMBINED SINGLE LIMIT <br />Eaaccid n 1,000,000 <br />BODILY INJURY (Per person) S <br />B <br />X <br />ANY AUTO <br />ALL OWNED SCHEDULED <br />AUTOS AUTOS <br />SSIStiI 1 Clt <br />-810-5729B 97 -TCT -1 <br />Attorne{� <br />2/1/201 <br />2/1/2012 <br />BODILY INJURY (Per accident) S <br />PROPERTY DAMAGE S <br />Per accident <br />X <br />HIRED AUTOS X NON -OWNED <br />AUTOS <br />Underinsured motorist BI s h $ <br />X <br />UMBRELLALIAB <br />X <br />OCCUR <br />EACH OCCURRENCE $ 5,000,000 <br />AGGREGATE $ 5,000,000 <br />A <br />EXCESS LIAR <br />CLAIMS -MADE <br />X 10,000 <br />DED $ <br />AETENTION <br />S <br />SM-CUP-8193B99A-TIL-11 <br />2/1/2011 <br />2/1/2012 <br />A <br />WORKERS COMPENSATION <br />ANO EMPLOYERS' LIABILITY y / N <br />ANY PROPRIETORrPARTNER)EXECUTNE E <br />OFFICERIMEMBER EXCLUDED? <br />(Mandatory In NIH)PJ-UB-8193B99-A-11 <br />N / A <br />2/1/2011 <br />12/1/2012 <br />X I WC STATU- OTH- <br />E.L. EACH ACCIDENT $ 500,000 <br />E.L. DISEASE - EA EMPLOYEE $ 500,000 <br />If yes, describe under <br />DESCRIPTION OF OPERATIONS below <br />E.L. DISEASE - POLICY LIMIT $ 500,000 <br />C <br />Professional Liability <br />16017332 <br />2/1/2011 <br />2/1/2012 <br />Per Claim $2,000,000 <br />Aggregate $2,000,000 <br />DESCRIPTION OF OPERATIONS/ LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) <br />Re: McFadden McDonalds. The City of Santa Ana, its officers, employees & volunteers are named as <br />Additional Insureds on the above referenced liability policies with the exception of workers compensation <br />& professional liability. Umbrella Follows Form. <br />CERTIFICATE HOLDER CANCELLATION <br />ACORD 25 (2010/05) <br />INS025 (201005).01 <br />© 1988-2010 ACORD CORPORATION. All rights reserved. <br />The ACORD name and logo are registered marks of ACORD <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 <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />Planning Division <br />AUTHORIZED REPRESENTATIVE <br />P.O. Box 1988 <br />M-20 <br />Santa Ana, CA 92702 <br />Matias Ormaza/JERRY <br />ACORD 25 (2010/05) <br />INS025 (201005).01 <br />© 1988-2010 ACORD CORPORATION. All rights reserved. <br />The ACORD name and logo are registered marks of ACORD <br />