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ACbRQM CERTIFICATE OF LIABILITY INSURANCE <br />ATE (MM/DD/YYYY) <br />D02/13/2013 <br />THIS CERTINCATE 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 endoroement.,A stfinent on this certificate does not confer rights to the <br />certificate holder in lieu of such endorsement(s). - <br />PRODUCER <br />Wigmore Insurance Agency, Inc. <br />2970 Harbor Blvd. #215E <br />License #0811959 <br />Costa Mesa, CA 92626 <br />CONTACT NAME: Ken Noden <br />AIC PHONE o. ,714.979.6543 No. 714.549.2943 <br />-MAIL <br />ADDRESS: <br />INSURER(S) AFFORDING COVERAGE NAIC if <br />INSURER A: Essex Insurance Company 39020 <br />INSURED Forfeiture Consulting Services <br />Joseph R La Rosa Jr. <br />9199 Poinsettia Avenue <br />Fountain Valley, CA 92 708 <br />INSURERS: <br />INSURERC: <br />INSURER D: <br />INSURER E: <br />INSURER F: <br />COVERAGES CERTIFICATE NUMBER: Z01Z GL 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 />ILTR <br />TYPE OF INSURANCE <br />INSR <br />WVD <br />POLICY NUMBER <br />MMIDD/YYYY <br />MM/DD/YYYY <br />LIMITS <br />Timothy Wigmore/G128 <br />GENERAL LIABILITY <br />CL0418OS77 <br />12/22/2012 <br />12/2212013 <br />EACH OCCURRENCE $ 1,000,00 <br />X COMMERCIAL GENERAL LIABILITY <br />PREMISES (Ea occurrence) $ 100,00 <br />CLAIMS -MADE 1-K OCCUR <br />MED EXP (Any one person) $ 5,00 <br />A <br />X <br />PERSONAL a ADV INJURY $ EXCLUDE <br />GENERAL AGGREGATE $ 2,000,001 <br />GEN'L AGGREGATE LIMIT APPLIES PER: <br />PRODUCTS - COMP/OP AGG $ EXCLUDE <br />POLICY PRO LOC <br />JECT <br />$ <br />AUTOMOBILE <br />LIABILITY <br />(Ea accident) $ <br />BODILY INJURY (Per person) $ <br />ANY AUTO <br />ALL OWNED SCHEDULED <br />AUTOS AUTOS <br />BODILY INJURY (Per accident) $ <br />NON -OWNED <br />HIRED AUTOS AUTOS <br />(Par accident) $ <br />UMBRELLA LIAB <br />OCCUR <br />EACH OCCURRENCE $ <br />EXCESS LIAB <br />CLAIMS -MADE <br />AGGREGATE $ <br />DED RETENTION $ <br />$ <br />WORKERS COMPENSATION <br />AND EMPLOYERS' LIABILITY Y / N <br />ANY PROPRIETOR/PARTNER/EXECUTIVEL <br />OFFICER/MEMBER EXCLUDED? U <br />N / A <br />�y 1� ♦ c� <br />APPROVED A S 1 <br />F0 <br />a <br />!/ <br />l <br />TORY LIMITS ER <br />E. L. EACH ACCIDENT $ <br />E.L. DISEASE - EA EMPLOYE $ <br />(Mandatory in NH) <br />i %�(I t <br />Za <br />0 yes, describe under <br />DESCRIPTION OF OPERATIONS below <br />2 A JR0&qiIni <br />E.L. DISEASE -POLICY LIMIT $ <br />Assistant City At <br />orney <br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) <br />ity of Santa Ana, its officers, employees, agents, volunteers and representative are named as <br />dditional insured. <br />OCATION: 60 CIVIC CENTER PLAZA SANTA ANA , CA 92702 <br />HIS CERTIFICATE REPLACES THE CERTIFICATE ISSUED ON 12/18/2012. ENDORSEMENT TO FOLLOW. <br />NCELLATION NOTICE IS 10 DAYS IN THE EVENT OF NON PAYMENT OF PREMIUM. <br />CERTIFICATE HOLDER CANCELLATION <br />©1988-2010 ACORD CORPORATION. All rights reserved. <br />ACORD 25 12010/051 The ACORD name and loco 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 />ACCORDANCE WITH THE POLICY PROVISIONS. <br />CITY OF SANTA ANA <br />AUTHGRMED REPRESENTATIVE <br />60 CIVIC CENTER PLAZA <br />SANTA ANA, CA 92702 <br />Timothy Wigmore/G128 <br />©1988-2010 ACORD CORPORATION. All rights reserved. <br />ACORD 25 12010/051 The ACORD name and loco are registered marks of ACORD <br />