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ORANCNT -01 PATRA5
<br />CERTIFICATE OF LIABILITY INSURANCE
<br />COVERAGES CERTIFICATE NUMBER: REVISION Kul IrulRCO.
<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 />DATE YY)
<br />TYPE OF INSURANCE
<br />1012 312 01
<br />14!23!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 />Pā' OW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
<br />( (ESENTATIVE 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 />PRODUCER
<br />Chapman
<br />a Division of Arthur J. Gallagher & Co,
<br />Insurance Brokers of California, Inc.
<br />PO BOX 5455
<br />CONTACT
<br />NAME:
<br />WC, PHONE N 1 626 405 -8031 FAx 1 626 405 -0585
<br />ac Eal 7 Arc No : ( j
<br />E-MAIL
<br />ADDRESS:
<br />INSURERS AFFORDING COVERAGE
<br />NAIC N
<br />Pasadena, CA 91117 -0455
<br />INSURERA:GreatAmerican Insurance Company
<br />16691
<br />$ 1,000,000
<br />INSURED
<br />INSURER 8:
<br />X
<br />Orange County Asian & Pacific Islander Community Alliance
<br />Islander Comm Alliance
<br />INSURER C:
<br />10/15/2012
<br />INSURER D
<br />To
<br />PREMISES Ea occurrence
<br />12900 Garden Grove Blvd #214A
<br />INSURER E:
<br />$ 5,000
<br />Garden Grove, CA 92843
<br />INSURER F:
<br />COVERAGES CERTIFICATE NUMBER: REVISION Kul IrulRCO.
<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
<br />LTR
<br />TYPE OF INSURANCE
<br />ADOLSUBR
<br />INSR
<br />WVD
<br />POLICY NUMBER
<br />POLICY EFF
<br />MM /DD/YYYY
<br />POLICY EXP
<br />MM / DD
<br />LIMITS
<br />GENERAL LIABILITY
<br />EACH OCCURRENCE
<br />$ 1,000,000
<br />A
<br />X COMMERCIAL GENERAL LIABILITY
<br />CLAIMS -MADE I A I OCCUR
<br />X
<br />PAC0330978
<br />10/15/2012
<br />1011512013
<br />To
<br />PREMISES Ea occurrence
<br />$ 100,000
<br />MED EXP (Any one person)
<br />$ 5,000
<br />X Professional Liab.
<br />PERSONAL & ADV INJURY
<br />$ 11000,000
<br />X
<br />Sexual Abuse
<br />GENERAL AGGREGATE
<br />$ 2,000,000
<br />_GEN'L AGGREGATE LIMIT APPLIES PER:
<br />POLICY PEA F7 LOC
<br />PRODUCTS - COMP /OP AGG
<br />$ 2,000,000
<br />$
<br />tJTOMOMLE
<br />A
<br />LIABILITY
<br />ANY AUTO
<br />PAC0330978
<br />10/15/2012
<br />10115/2013
<br />EOMBIBI aeD SINGLE LIMIT
<br />$ 1,000,000
<br />BODILY INJURY (Per person)
<br />$
<br />ALL OS SCHEDULED
<br />AUTOS AUTOS
<br />BODILY INJURY (Per
<br />( )
<br />$
<br />X
<br />HIRED AUTOS X AUTOS NEO
<br />AUTOS
<br />PROPERTY DAMAGE
<br />Per accident
<br />$
<br />$
<br />UMBRELLA LIAB
<br />TCLAMS-MADE
<br />CUR
<br />EACH OCCURRENCE
<br />$
<br />AGGREGATE
<br />$
<br />EXCESS LIAR
<br />DED I RETENTION $
<br />$
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY Y / N
<br />ANY PROPRIETOR/PARTNER /EXECUTIVE
<br />OFFICERIMEMBER EXCWDEI ā
<br />NIA
<br />WC STATU- OTH-
<br />TORY LIMIT ER
<br />E.L. EACH ACCIDENT
<br />$
<br />E.L. DISEASE - EA EMPLOYEE
<br />$
<br />(Mandatory in NH)
<br />if yes, describe under
<br />E.L. DISEASE - POLICY LIMIT
<br />$
<br />DESCRIPTION OF OPERATIONS hetow
<br />A
<br />Employee Dishonesty
<br />PAC0330978
<br />1011512012
<br />10/1512013
<br />Deductiible: $1,000 50,000
<br />A
<br />Forgery & Alteration
<br />PAC0330978
<br />10115/2012
<br />10/1512013
<br />Deductible: $1,000 50,000
<br />DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required)
<br />Re: WIA Youth Provider Agreements #Y6.2W -12 and Y6- CGRP -12. County of Orange, its elected and appointed officials, officers, employees, agents and
<br />volunteers are named addit)ona[ insured with respect to the operations of the named Insured per the attached CG2026 EndorsemenL Such insurance is
<br />plrmary and non - contributory per the attached endorsement.
<br />GERTIFIGAIE HOLDER CANCFI I ATICIN
<br />"7LriltS © 1988 -2010 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2010105) The ACORD name an fg s marks of ACORD
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 13EFORE
<br />County of Orange, Orange County
<br />Workforce Investment Board
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />Attn: Amy Harayda
<br />AUTHORIZED REPRESENTATIVE
<br />1300 S. Grand Ave., Bldg B, 3rd Fl
<br />Santa Ana, CA 42705
<br />I ā ā
<br />"7LriltS © 1988 -2010 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2010105) The ACORD name an fg s marks of ACORD
<br />
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