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.h <br />OP ID: PC <br />??` v?rc? CERTIFICATE OF LIABILITY INSURANCE 1 DAT0103D/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 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(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 />PRODUCER 626-405-8031 CONTACT <br />NAME: <br />Chapman 626-405-0585 <br />Li <br />#0 PHONE FAX AJC. <br />Ne Ext : aC No <br />cense <br />522024 <br />P <br />O <br />Box 5455 E--MM <br />AIL <br />ADDRESS: <br />. <br />. <br />Pasadena, CA 91117-0455 PRODUCER gACKT-1 <br />CUSTOMER ID a: <br /> INSURER(S) AFFORDING COVERAGE C # <br />INSURED Back do Natives Restoration INSURER A: NIAC NI <br />PO Box 653 9 INSURER B: Southern Insurance Com an F <br />Irvine, CA 92612-6539 INSURERC: <br /> INSURER D : <br />??? ?' --•+ <br />OL co 1 INSURER E : <br />1 INSURER F : <br />? V am/ "=J t-l ft 11F1t.m I t NI immFw- UC11101!1\l \111\ttGG?. <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 />, <br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br />INS TYPE OF INSURANCE POLICY NUMBER MMIDD>YEYYY MMIDI EYYYY) XP LIMITS <br /> GENERAL LIABILITY EACH OCCURRENCE E 1,000,00 <br />A X COMMERCIAL GENERAL LIABILITY X 201121765NPO 10/01/11 10/01/12 PRDAMAGE TO EMISES (Ea R occurrence $ 500,00 <br /> CLAIMS-MADE OCCUR VIED EXP (Any one person) $ 20,00 <br /> PERSONAL 8 ADV INJURY 000 <br />S 1 <br />00 <br /> , <br />, <br /> GENERALAGGREGATE 000 <br />00 <br />$ 2 <br /> , <br />, <br /> GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,00 <br /> RO POLICY P LOC $ <br /> AUT OMOBILE LIABILITY COMBINED SINGLE LIMIT <br /> <br />(Ea accident) $ 1,000,00 <br /> ANY AUTO <br /> <br />ALL OWNED AUTOS BODILY INJURY (Per person) S <br /> BODILY INJURY (Per accident) S <br /> SCHEDULED AUTOS <br /> <br />A <br />X <br />HIREDAUTOS <br />201121765NPO <br />10/01/11 <br />10101112 PROPERTY DAMAGE <br />(Per accident) <br />S <br /> X NON-OWNEDAUTOS $ <br /> <br /> <br /> UMBRELLA LM OCCUR EACH OCCURRENCE <br /> <br />EXCESS LIAB H <br />CLAIMS-MADE <br /> <br />AGGREGATE S <br /> <br />$ <br /> <br /> DEDUCTIBLE <br /> S <br /> RETENTION S S <br /> WORKERS COMPENSATION WC STATU- OTH- <br /> AND EMPLOYERS' LIABILITY <br />Y I N DR I <br />T Y IMIT R <br />B ANY PROPRIETOR/PARTNER/EXECUTIVE WS1004552201 10126/10 10126/11 <br /> <br />OFFICERIMEMBER EXCLUDED? F7 <br />N / A E.L. EACH ACCIDENT a 1,000,00 <br /> (Mandatory In NH) <br />It yes <br />describe under <br />r E.L. DISEASE - EA EMPLOYE S 1,000,00 <br /> , <br />DESCRIPTION OF O <br />below E. L. DISEASE -POLICY LIMIT $ 1,000,00 <br /> 1 A <br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) <br />Re: Use of City Premise at 600 E. Memory Lane, Santa Ana, CA 92705. The City <br />f S <br />t <br />A <br />% <br />? <br />o <br />an <br />a <br />na, its officers, employees, agents and volunteers are named ? <br />l <br />5 <br />1 <br />/ 1 <br />additional insured with respect to the operations of the named insured per <br />_" 4' r L t /?? <br />h <br />t <br />e attached CG 2026 endorsement. Such insurance is primary and s t1L' ? <br />t <br />i <br />, <br />non-con <br />r <br />butory per the attached endorsement. -L ; <br />CITYSA1 <br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br /> THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />The City of Santa Ana ACCORDANCE WITH THE POLICY PROVISIONS. <br />20 Civic Center Plaza <br />Santa Ana, CA 92702 <br />L. I AUTHORIZED REPRESENTATIVE <br />? &JA- l <br />W I VU?6-zoos ACORD CORPORATION. All rights reserved. <br />ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD <br />n _