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<br />CERTIFICATE OF COVERAGE
<br />DATE`MMID °YYYY,
<br />7
<br />PRODUCER
<br />NF ES NO
<br />THIS CERTIFICATE IS ISSUED AS A MATTER OF EVIDENCE ONLY AND CO NFFIRES NO RIGHTS
<br />TYPE OF COVERAGE
<br />UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR
<br />Alliant Insurance Services, Inc.
<br />100 Pine Street
<br />NEGATIVELY ry'D„ EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
<br />MEMORANDUM 1- C., ICyE(�LOfWW�•� +�+1 ''jj ,,++55
<br />THIS CERTIFICATE OF COVERAGE DOES 11+1, 2TITUTE A CONTRACT BETWEEN THE
<br />11th Floor
<br />ISSUING COVERAGE PROVIDER, AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE
<br />San Francisco CA 94111
<br />CERTIFICATE)!(4LDEE++��RRSs��
<br />7/1/2016
<br />IMPORTANT: IFITWE I@PIItTIF wt III ERjNSAp' ADDITIONAL COVERED PARTY, THE
<br />EACH OCCURRENCE
<br />MEMORANDU x,04 SAG S B NDORM .. A STATEMENT ON THIS CERTIFICATE
<br />DOES NOT FrER (if�GF Tti T , _fTOB 1C,ER'TiFICATE HOLDER IN LIEU OF SUCH
<br />ENDORSEMENT(S). - k. "_:- -
<br />IMPORTANT: IF SUBROGATION IS WAIVED, SUBJECT TO THE TERMS AND CONDITIONS OF THE
<br />NAMED COVERED PARTY
<br />CSU Fullerton Auxiliary Services Corporation
<br />2600 Nut wood Ave., Suite 275
<br />MEMDRANDUMNH OF COVERAGE AN ENDORSEMENT MAY BE REQUIRED, ASTATEMENT ON
<br />THE CERTIFICATE DOES NOT CONFER RIGHTS TO THE CERTIFICATE HOLDER IN LIEU OF SUCH
<br />ENDORSEMENT(S).
<br />Fullerton CA 92631 -3599
<br />PROGRAM AFFORDING COVERAGE
<br />A: CSURMA AORMA s_e,
<br />B :AORMA WC/Safety National Cas.
<br />CLAIMS MADE OCCUR
<br />Ct
<br />COVERAGES
<br />THIS IS TO CERTIFY THAT THE COVERAGE IS AFFORDED TO THE ABOVE NAMED MEMBER, AS PROVIDED BY THE MEMORANDUMS) OF COVERAGE, FOR THE PERIOD SHOWN BELOW, NOT WITHSTANDING ANY
<br />REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE COVERAGE AFFORDED BY THE PROGRAM
<br />DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS, AND CONDITIONS OF SUCH MEMOBANDUMC) OF COVERAGE. THE FOLOWING COVERAGE IS IN EFFECT.
<br />JPA
<br />LTR
<br />TYPE OF COVERAGE
<br />MEMORANDUM NUMBER
<br />COVERAGE EFFECTIVE
<br />DATE(MWODNY)
<br />COVERAGE EXPIRATION
<br />DATE(MMIODIYY)
<br />LIMITS
<br />A
<br />GENERAL LIABILITY
<br />AORMA- 1617 -01
<br />7/1/2016
<br />7/1/2019
<br />EACH OCCURRENCE
<br />$5,000,000
<br />FIRE DAMAGE (Any one fire)
<br />S
<br />COMMERCIAL GENERAL LIABILITY
<br />CLAIMS MADE OCCUR
<br />MEO EXPENSE (Any one Pereen)
<br />$5,000
<br />PERSONAL &ADV INJURY
<br />$5,000,000
<br />Prof Liability
<br />2L
<br />CnntractiTal T,� So
<br />GENERAL AGGREGATE
<br />$5,000,000
<br />GEN'LAGGREGATE LIMIT APPLIES PER
<br />PRODUCTS- COMPIOPAGG
<br />$5,000,000
<br />MEM"9 PROJECT LOC
<br />-
<br />A
<br />AUTOMOBILE
<br />LIABILITY
<br />AORMA- 1.617 -01
<br />7/1/2016
<br />7/1/2017
<br />COMBINED SINGLE LIMIT
<br />$5,000,000
<br />$
<br />ANY AUTO
<br />(So accident
<br />ALL OWNED AUTOS
<br />N
<br />SCHEDULED AUTOS
<br />X
<br />HIRED AUTOS
<br />NON OWNED AUTOS
<br />H
<br />WORKERS' COMPENSATION AND
<br />EMPLOYERS LIABILITY
<br />AORMA -WC -1617
<br />7/1/2016
<br />7/1/2017
<br />MOD X STATVTORV OTHER
<br />LIMITS
<br />ANY PROPRIETORIPARTNERI
<br />EXECUTIVE)OFFICERIMEMBER
<br />°
<br />E L EACII ACCIDENT
<br />$5,000,000
<br />EXCLUDED?
<br />IF YES, DESCRIBED UNDER SPECIAL
<br />-
<br />EL DISEASE - EA EMPLOYEE
<br />$5,000,000
<br />E.L. DISEASE - POLICY LIMIT
<br />$5,000,000
<br />PROVISION BELOW
<br />OTHER
<br />OTHER d
<br />DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLES )EXCLUSIONS ADDED BY ENDORSEMENTISPECIAUPROVISIONS
<br />Note: Workers' Compensation Coverage is provided as evidence only.
<br />City of Santa Ana and the State of California are named as additional covered parties as
<br />respects the Agreement under the Workforce Investment Act. Term of Agreement: December 1,
<br />2011 - November 30, 2016.
<br />CERTIFICATE HOLDER CANCELLATION
<br />City of Santa
<br />Ana
<br />SHOULD ANY OF THE ABOVE DESCRIBED MEMORANDUM(S) OF COVERAGE
<br />P,O. Box 1988
<br />(M -73)
<br />BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE
<br />Santa Ana CA
<br />92702
<br />DELIVERED IN ACCORDANCE WITH THE MEMORANDUM(S) OF COVERAGE
<br />PROVISIONS.
<br />AUTHORIZED REPRESENTATIVE -,Pb
<br />
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