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,a?co d CERTIFICATE OF LIABILITY INSURANCE F02/011/2012 <br />/2012 <br />°A'?` <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 pollcy(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 1-909-243-8200 NAME <br />Hays of California Insurance Services - Ontario PHO <br />M_. EatI, NE {909) 243-8200 AX <br />Empire Torero IV EMAIL AIC No: <br />DRESS: <br />3800 Contours, Suite 3400 PRODUCER <br />Ontario, CA 91764 CUSTOMER ID 0, <br />INSURED <br />Clinical Laboratories of San Bernardino, Inc. <br />P.O. Box 329 <br />San Bernardino, CA 92402 <br />COVERAGES <br />CERTIFICATE NUMBER: 25423462 <br />A: Continental <br />INSURERB: Transportation Insurance Co. <br />wsul;ERC: The Hartford Insurance Comps <br />IISURERD: Columbia Casualty Company <br />INSURER E <br />REVISION NUMBER: <br />NAIC 0 <br />I rns 15 1 U cEHTIFY 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 />INSR <br />LTR <br />TYPE Of INSURANCE POLICY EFF POLICY EXP <br />POLICY NUMBER M -_, .'.. <br />LIMITS <br />A am ERALLMILITY 2068975201 02101/1 02/01/13 EACH OCCURRENCE $ 1,000,000 <br /> X; <br />- COMMERCIAL GENERAL LIABILITY PDAMAGE TO REMISES s u <br />rtenca <br />f 100,000 <br /> CLAIMS-MADE n <br />1? J OCCUR <br />MED EXP (Any one person) <br />S 10.000 <br /> PERSONAL 6 ADV INJURY S 1, 000, 000 <br /> <br /> GENERAL AGGREGATE S 2,000,000 <br /> GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ Zxcluded <br /> POLICY LOC $ <br />A AU TOMOBILE LIABILITY 2068975084 02/01/1; 02/01/13 COMBINED SINGLE LIMIT <br /> <br />(Ee accident) f 1, 000, 000 <br /> X ANY AUTO <br /> <br />ALL OWNED AUTOS BODILY INJURY (Per parson) $ <br /> SCHEDULED AUTOS BODILY INJURY (Per accident) $ <br /> <br /> <br />X -- <br />PROPERTY DAMAGE -- ------------- <br /> <br />f <br /> HIRED AUTOS (Per accident) <br /> X NON-OWNED AUTOS $ <br /> S <br />B X UMBRELLA LIAB Z OCCUR 2068975344 02/01/1 02/01/13 EACH OCCURRENCE <br />- $ 5,000,000 <br /> EXCESS LIAR CLAIMS?M,DE AGGREGATE f 5, 000, 000 <br /> <br /> <br /> <br />k DEDUCTIBLE <br />S <br /> X RETENTION 0 <br />C WORKERS COMPENSATION 411FZ4190ZE 02/01 02/01/13 WCSTATU• OTH- <br /> AND EMPLOYERS' LIABILITY YIN /1 <br /> <br />ANY PROPRIETORIPARTNERIEXECUTIVE <br />OFFICER/MEMBER EXCLUDED? I <br /> <br />N I A <br />E.L. EACH ACCIDENT <br />_T..,..__._.._ ------ <br />f 1,000,000 <br /> (Mandatory In NH) <br />If ea <br />describe under E.L. <br />DISEASE - EA EMPLOYE <br />-• - <br />S 1,000,000 <br /> , ----_ <br /> DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT S1,000,000 <br />D Professional y J 27-61 - - C a ma Ito • J'UUU'UUU D111141001000 <br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Ia required) <br />Certificate holder is named as additional insured as respects General Liability only. <br />10 day cancellation notice for non payment of premium. <br />City of Santa Ana <br />Dept. of Public Works -? <br />220 S. Daisy Avenue <br />Santa Ana, CA 92703-4334 <br />USA <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />AUTNORO:ED REPRESENTATIVE <br />Kelly Peterson <br /> <br />,... W 1988-2009 ACORD CORPORATION. All rights reserved. <br />ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD V <br />25423462 <br />Certificate Delivery by CertificatesNow - www.ConfirmNat.com - 877.669.8600 r