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® A ° CERTIFICATE OF LIABILITY INSURANCE DATE (MM1DOlYrYYY) 3/15/2012 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAMP Lena Bargas Lake Insurance Agency PHONE (714)838-1912 FAA/C No: (714) 838-7568 653 South B Street, Suite 200 E-MAIL ADDRESS: Lic #0747473 INSURERS AFFORDING COVERAGE NAIC# Tustin CA 92780 INSURER A:Philadel hia Ind. Ins. Co. INSURED INSURER B:Philadel hia Insurance Co. The Cambodian Family INSURERC-Ace Property And Casualty Ins 4th Street 1626 E INSURER D: . INSURER E : Santa Ana CA 92701 INSURER F: RAGES CERTIFICATE NUMBER•CL1231500133 REVISION NUMBER: COVE THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS INDICATED . CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL SU D POLICY NUMBER MM DDY/YYYY MMIDDNYYY LIMITS GENERAL LIABILITY X EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 100 000 comMERCIAL GENERAL LIABILITY PREMISES Ea occurrence , $ A CLAIMS-MADE ? OCCUR HPK825234 03/09/2012 03/09/2013 MED EXP (Any one person) $ 5 , 000 n PERSONAL & ACV INJURY $ 1,000,000 GENERAL AGGREGATE $ 3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOP AGG $ 1,000,000 X POLICY PRO LOC IFCT $ AUTOMOBILE LIABILITY Ea accident) SINGLE LIMIT $ 1,000,000 X ANY AUTO BODILY INJURY (Per person) $ A 2013 ALL OWNED SCHEDULED HPK825234 03/09/2012 03/09/ BODILY INJURY (Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ X HIRED AUTOS X Per accident AUTOS Non-owned $ 1,000,000 X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1f000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 B 10 00 X HUB372976 03/09/2012 03/09/2013 $ , RETENTIONS DED WORKERS COMPENSATION Y WC STATU- OTH- FIR AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE 46440390 06/30/2012 06/30/2013 E.L. EACH ACCIDENT $ 1 000 000 CER/MEMBER EXCLUDED? FF NIA C I O (Mandatory in NH) E.L. DISEASE - EA EMPLOYE $ 1,000,000 Ifyes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 A Professional Liability HPK825234 05/25/2012 03/09/2013 Aggregate $3,000,000 Each Incident $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Employee Dishonesty $200,000/$2,500 Ded. City of Santa Ana is additional insured per contract with named 0 insured Schedule of vehicles and drivers on file. "Non Profit organization" 50 ? . O G? S S i. Qrn `J ;zN CFRTIGICATE HOLDER CANCELLATION S (714) 571-1974 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Santa Ana Community Development Agency CDBG-M-25 AUTHORIZED REPRESENTATIVE P.O. Box 1988 Santa Ana, CA 92702 Bob Lake-C/L/LENA ACORD 25 (2010/05) I N S025 rent nnFt m © 1988-2010 ACORD CORPORA LION. An rights reserved. The Arr)pn name and Innn arc reniefererf mar4c of Ar-r)Pn