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A'ZI I <_
<br />BACKTON -02 VPPGOSWAMI
<br />CERTIFICATE OF LIABILITY INSURANCE
<br />1 DATE 4 /3 /2 0114 4 Y)
<br />4/3/2
<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 />PRODUCER License # 0726293
<br />Arthur J. Gallagher & Co. Insurance Brokers of CA, Inc.
<br />505 N Brand Blvd, Suite 600
<br />Glendale, CA 91203
<br />CONTACT
<br />NAME:
<br />PHONE FAX
<br />AIC Na Ea: (818) 539 -2300 AIC, Had (818) 539 -2301
<br />E -MAIL
<br />ADDRESS:
<br />INSURER(S) AFFORDING COVERAGE
<br />NAIC #
<br />INSURER A: Nonprofits' Insurance Alliance of CA
<br />LIMITS
<br />INSURED _
<br />Z�'(r EJ��
<br />Back to Natives Restoration
<br />PO Box 6539
<br />Irvine, CA 92612.6539
<br />INSURER B1 State Compensation Insurance Fund of CA
<br />35076
<br />INsuRERc:Old Republic Surety Company
<br />40444
<br />INSURER D
<br />INSURER E:
<br />$ 1,000,00
<br />INSURER F:
<br />X COMMERCIAL GENERAL LIABILITY
<br />CLAIMS -MADE OCCUR
<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 />I NSR
<br />R
<br />TYPE OF INSURANCE
<br />INSR
<br />MD
<br />POLICY NUMBER
<br />MMIDOP/YYY
<br />MMIOD EXP
<br />M'YY
<br />LIMITS
<br />GENERAL LIABILITY
<br />EACH OCCURRENCE
<br />$ 1,000,00
<br />A
<br />X COMMERCIAL GENERAL LIABILITY
<br />CLAIMS -MADE OCCUR
<br />X
<br />201321765NPO
<br />10/0112013
<br />10101/2014
<br />PREMISES Eaoacurrence
<br />$ 500.00
<br />MED EXP(Any one person)
<br />$ 20,000
<br />PERSONAL &ADV INJURY
<br />$ 1,000,00
<br />GENERAL AGGREGATE
<br />$ 2,000,00
<br />GEN'L AGGREGATE
<br />LIMIT APPLIES PER:
<br />PRODUCTS - COMPIOP AGO
<br />$ 2,000,00
<br />POLICY
<br />PRO LOC
<br />JCT
<br />$
<br />AUTOMOBILE
<br />LIABILITY
<br />COMBINED SINGLE LIMIT E
<br />a accident
<br />$ 1,000,00
<br />BOD ILY INJURY (Per person)
<br />$
<br />A
<br />X
<br />ANY AUTO
<br />201321765NPO
<br />10101/2013
<br />10/01/2014
<br />ALLOWNED SCHEDULED
<br />AUTOS AUTOS
<br />BODILY INJURY (Per accident)
<br />$
<br />HIRED AUTOS NON - OWNED.
<br />AUTOS
<br />PROPERTY DAMAGE
<br />PERACCIDENT
<br />$
<br />$
<br />UMBRELLA LIAB
<br />OCCUR
<br />EACH OCCURRENCE
<br />$
<br />AGGREGATE
<br />$
<br />EXCESS LAS
<br />CLAIMS -MADE
<br />DED I I RETENTION$
<br />$
<br />B
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY
<br />ANY PROPRI ETC R/PARTNERJEXECUTIVEYIN
<br />OFFICER/MEMBER EXCLUDE D?
<br />(Mandatary in NH)
<br />NIA
<br />9078164.2013
<br />1012612013
<br />10126/2014
<br />TWO STATU- OTH-
<br />TORY LIMITS ER
<br />E.L. EACH ACCIDENT
<br />$ 1,000,00
<br />E.L. DISEASE - EA EMPLOYEE
<br />$ 1,000,00
<br />If yes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />E.L. DISEASE - POLICY LIMIT
<br />$ 1,000,00
<br />A
<br />Abuse
<br />201321765NPO
<br />10/01/2013
<br />10/0112014
<br />Occ /Agg 1,000,00
<br />C
<br />Bond
<br />W150092079
<br />04113/2013
<br />04/1312014
<br />12,500
<br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required)
<br />Re: Use of City Premise at 600 E. Memory Lane, Santa Ana, CA 92705. The City of Santa Ana, its officers, employees, agents and volunteers are named
<br />additional insured with respect to the operations of the named insured per thg,:3tfd;41p CG 2026 endorsement. Such insurance is primary and
<br />non - contributory per the attached endorsement. Workers Compensatiol oveFF g excluded, evidence only.
<br />alj)a
<br />1-°
<br />CERTIFICATE HOLDER __I; taut UI`Y CANCELLATION
<br />ACORD 25 (2010/05)
<br />©1988 -2010 ACORD CORPORATION. All rights reserved.
<br />The ACORD name and logo are registered marks of ACORD
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />The City of Santa Ana
<br />20 Civic Center Plaza
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />Santa Ana, CA 92702
<br />AUTHORIZED REPRESENTATIVE
<br />ACORD 25 (2010/05)
<br />©1988 -2010 ACORD CORPORATION. All rights reserved.
<br />The ACORD name and logo are registered marks of ACORD
<br />
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