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MART <br />CERTIFICATE OF LIABILITY INSURANCE vv) <br />DA <br /> 5/15/2012 <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 /> <br />PRODUCER (949) 221-1788 CONTACT <br />NAME: Jennifer Martinez <br />D.L.D. Insurance Brokers, Inc. ac° o Ext: 949 553-5695 ac No: 949 221-1799 <br />Lic#OD25325 ADDRESS: imartinez@dldins.com <br />17712 Mitchell North PRODUCER #:GOODIND-01 <br />Irvine, CA 92614 --_-- <br /> INSURER(S) AFFORDING COVERAGE NAIC # <br />INSURED Goodwill Industries of Orange County INSURER A:Philadelphia Indemnity Insurance Co. <br />410 North Fairview INSURER B : <br />Santa Ana, CA 92703- INSURER C <br /> INSURER D <br /> INSURER E <br /> INSURER F : <br />COVERAGES CERTIFICATE NUMBER: 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 />INSR - - A DDLIUBR T POLICY EFF POLICY EXP LIMITS <br />LTR TYPE OF INSURANCE POLICY NUMBER MM/DDNYYY MM/DD/YYYY <br />GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 <br /> <br />X COMMERCIAL GENERAL LIABILITY ! <br />A <br /> <br />PHPK742566 <br /> <br />7/1/2011 <br />$ <br />DAMAGE ORENT?D <br />300,00( <br />71112012 PREMISES (Ea occurrence) <br />- F-- <br />CLAIMS-MADE X OCCUR MED EXP (Any one person) $ 15,00 <br /> j PERSONAL & ADV INJURY $ 11000,00 <br />- <br />j j GENERAL AGGREGATE $ 3,000,00 <br />GENT AGGREGATE LIMITAPPLIES PER PRODUCTS - COMPIOP AGG $ 3,000,00 <br />POLICY 1 PRO X LOC Deductible $ Non <br />AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,00 <br /> <br />A X ANY AUTO <br />PHPK742566 <br />711/2011 (Ea accident) <br />7/1/2012 --- - - -- - - - <br /> BODILY INJURY (Per person) $ <br />ALL OWNED AUTOS BODILY INJURY (Per accident) $ <br />!I SCHEDULED AUTOS <br />PROPERTY DAMAGE $ <br />,V <br />HIRED AUTOS' v? Per accident) <br />l <br />NON-OWNED AUTOS <br /> <br />V A„? a• <br />D ,_ _ <br />- <br />X Comp / Coll Ded. - $1,000 O $ <br /> UMBRELLA LIAB <br />OCCUR <br />(F /?1_7_ EACH OCCURRENCE $ <br /> EXCESS LIAB CLAIMS-MADE <br /> <br />-MADE <br />H I ? E• S? R C(10y A <br />AGGREGATE $ <br />tO -- -- - <br /> DEDUCTIBLE <br />1 ! L <br />S? <br />PS S ?? G1ty <br />to ? <br />---$ <br />? --- --- r - -- -- -_ <br /> RETENTION $ $ <br />WORKERS COMPENSATION WC STATU- BOTH-. <br />AND EMPLOYERS' LIABILITY Y I N L?RY LIMITS?___ _ ER_ <br />T + <br />ANY PROPRIETOR/PARTNER/EXECUTIVE <br />- E L EACH ACCIDENT $ <br />] <br />OFFICER/MEMBER EXCLUDED? F <br />N / A <br />(Mandatory in NH) E L. DISEASE EA EMPLOYEE <br />$ <br /> <br />If yes, describe under ! _ <br />_ <br />-- -- --- -- -I- - - _ - <br />DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ <br />A '(Professional Liability PHPK742566 711/2011 7/1/2012 IEa Incident/Aggregate $1,000,000/$3,000,00 <br />A (Sexual Misconduct PHPK742566 711/2011 7/1/2012 'Ea Incident/Aggregate $1,000,0001$3,000,00 <br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) <br />CERTIFICATE HOLDER CANCELLATION <br />Santa Ana Youth Council <br />Workforce Investment Board <br />1000 E. Santa Ana Blvd., Suite 200 <br />Santa Ana, CA 92701- <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 />AUTHORIZED REPRESENTATIVE <br />C_._ <br />© 1988-2009 ACORD CORPORATION. All rights reserved. <br />ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD