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BACKTON -01 DDIAZ
<br />CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD— YYYy)
<br />10/1112012
<br />_
<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
<br />I CONTACT
<br />Chapman
<br />a Division of Arthur J. Gallagher & Co.
<br />'PO
<br />NAME:
<br />PHONE FAX --
<br />AIC,No Ex,e 1 (626) 405 -8031 N°): 1 (626) 405 -0585
<br />E-MAIL
<br />ADDRESS:
<br />- —
<br />Insurance Brokers of California, Inc.
<br />Box 5455
<br />Pasadena, CA 91117 -0455
<br />- --
<br />INSURER(S) AFFORDING COVERAGE__
<br />NAIC #
<br />f- --- ---
<br />PERSONAL 8 ADV INJURY ! $ 1,000,000
<br />INSURER A: Nonprofits' Insurance Alliance of California _
<br />011845 - -�
<br />INSURED
<br />INSURER B, New York Marine and General Insurance Company
<br />16608
<br />INSURER C_
<br />Back to Native Restoration
<br />_ - -_- _ -__ -- -_ - -11+
<br />_
<br />A
<br />PO Box 6539
<br />Irvine,
<br />INSURER D:
<br />10/1/2012
<br />CA 92612 -6539
<br />INSURER E:
<br />r ALL OWNED ! SCHEDULED
<br />INSURER F:
<br />- --
<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 />EXCI I ISInNR ANn r.nNnITInNS r1F RI Ir.H Onl IL:IF3 I IMITS SHnWN MAY HAVF RFFN RFnI ICFn RY PAIn r:l AIMS
<br />INS
<br />LTR
<br />-.- ,A�; us
<br />TYPE OF INSURANCE IN R WVD
<br />I GENERAL LIABILITY - _---- -_-- �� - -- -- i
<br />L-
<br />POLICY NUMBER
<br />POLICY EFF
<br />MMIDD6FYFY
<br />POLICY EXP -- - - - - --
<br />MMIDD /YYYY LIMITS
<br />I
<br />EACH OCCURRENCE $ 1,000,000
<br />A
<br />X11 COMMERCIAL GENERAL LIABILITY j X
<br />201221765NPO
<br />10/1/2012
<br />10/1/2013 PREMISES Ea occurrence $ 500,000
<br />r_ CLAIMS -MADE �X, OCCUR
<br />M_ED EXP (Any one person) $ 20,000
<br />'---
<br />— — - - -- -- --
<br />f- --- ---
<br />PERSONAL 8 ADV INJURY ! $ 1,000,000
<br />�__ -, .--- ._- .--- --- -- -. --'
<br />r - - - - --
<br />`GENERAL AGGREGATE_--
<br />GEN'L AGGREGATE LIMIT APPLIES PER.
<br />r n L__
<br />- -$ ---- .__.2,000,000
<br />I PRODUCTS - COMP /OP AGG $ 2,000,000
<br />I - -- --'-------- -- - - - - --�
<br />_
<br />A
<br />POLICY I LOC __ ..�
<br />AUTOMOBILE LIABILITY
<br />)._
<br />ANY AUTO
<br />_ —_-
<br />!
<br />I201221765NPO
<br />10/1/2012
<br />— .___ -__�—
<br />T- COMBINED —SING
<br />I LfEa accident - - -.i $ -- - - - -- 1,000,00
<br />1011/2013 BODILY INJURY (Per person? $
<br />r ALL OWNED ! SCHEDULED
<br />- ----...---------
<br />i
<br />BODILY INJURY Per accide,t)' a'
<br />i- •AUTOS AUTOS
<br />-- !
<br />i X HIRED AUTOS NON -OWNED
<br />X, AUTOS
<br />UMBRELLA LIAB OCCUR I
<br />-
<br />EXCESS LIAB CLAIMS -MADEI
<br />I
<br />-- - ------ ----- -- - - --
<br />I
<br />I r PROPERTY DAMAGE - - - -- - - - - - -- - - - - -- -
<br />{Per accidenlL_ __ _ 5
<br />r- -- ---' - . --... ----------- - ----
<br />- - --
<br />EACH OCCURRENCE $
<br />------- - ------ -'- -- ---' ------ --- - ----I
<br />AGGREGATE $
<br />--
<br />DED RETENTION$ - +- - -I` ---
<br />WORKERS COMPENSATION i
<br />AND EMPLOYERS' LIABILITY
<br />fWC201200000404
<br />-—�
<br />WC STATU- j OTH -;
<br />- TORY LIMITS1 ER
<br />B
<br />YIN
<br />OFFICERIMEMBER /EXCLUDEDXECUTIVE ' - � I N I A j
<br />10/2612012
<br />-_- ---- --- --- - - --
<br />10/26/2013 1 E L. EACH ACCIDENT _ _- $ 1,000,000
<br />—__-
<br />__.�____
<br />(Mandatory in NH) (
<br />E.L. DISEASE - EA EMPLOYEE $ 1,000,000
<br />If yes, describe under
<br />DESCRIPTION OF OPERATIONS below I
<br />I
<br />-- - - - --
<br />E.L. DISEASE - POLICY LIMIT l $ 1,000,000
<br />I
<br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attarh 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 namefj,
<br />additional insured with respect to the operations of the named insured per the attached CG 2026 endorsement. Such insurance is primary an d ®
<br />,,Aso �^
<br />non - contributory per the attached endorsement.
<br />N
<br />CERTIFICATE HOLDER
<br />The City of Santa Ana
<br />20 Civic Center Plaza
<br />Santa Ana, CA 92702
<br />g c
<br />R
<br />_ E• S _P_tt_ °__c_r_ y
<br />CANCELLATION
<br />- - -i -- - - - -- - - -- -- - - PSSxgtar- . _ -- - --
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANOE LLED BE ORE III
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERE IN
<br />ACCORDANCE WITH THE POLICY PROVISIONS. -
<br />i
<br />AUTHORIZED REPRESENTATIVE
<br />©1988 -2010 ACORD CORPORATION. All rig tits reserved.
<br />ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD
<br />
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