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Ilk ArM <br />BACKTON -01 PATRA4 <br />"" CERTIFICATE OF LIABILITY INSURANCE <br />� DATD/YYYY) <br />100/5/2/5 /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 />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 pollcy(les) 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 i <br />certificate holder in lieu of such endorsement(s). <br />_ <br />PRODUCER; CONTACT <br />NAME: <br />Chapman PHONE 1 626 40 FAX <br />) 5 <br />a Division of Arthur J. Gallagher & Co. a/c No Ext : -8031 (A/c, No): 1 (626) 405 -0585 <br />Insurance Brokers of California, Inc. E-MAIL — <br />PO Box 5455 ADDRESS: - - - -- <br />Pasadena, CA 91117 -0455 INSURER(S) AFFORDING COVERAGE NAIC p — <br />INSURER A: Nonprofits' Insurance Alliance of California 011845 <br />INSURED INSURER B; New York Marine and General Insurance Company 11'1 <br />Back to Native Restoration INSURER C: — {I_ <br />_ _ <br />PO Box 6539 INSURER D: <br />Irvine, CA 92612 -6539 INSURER E: <br />_ <br />L� INSURER F <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 />INSR <br />LTR <br />—_ TYPE OF INSURANCE <br />INSR <br />WVD <br />POLICY NUMBER <br />POLICY EFF <br />MM/DDlYYYY <br />POLICY EXP <br />MM /DD/YYW <br />LIMITS <br />GENERAL LIABILITY <br />EACH OCCURRENCE <br />$ 1,000,000 <br />A <br />GENERAL LIABILITY <br />X <br />201221765NP0 <br />10/1/2012 <br />10/1/2013 <br />PREMISES Ea occurrence <br />$ 500,000 <br />�"MERCIAL <br />CLAIMS -MADE �J OCCUR <br />MED EXP (Any one person) <br />$ 20,000 <br />PERSONAL & ADV INJURY <br />$ 1,000,000 <br />GENERAL AGGREGATE <br />$ 2,000,000 <br />GE_N'L AGGREGATE LIMIT APPLIES PER <br />r <br />PRODUCTS - COMP /OP AGG <br />$ 2,000,000 <br />- ---�� <br />POLICY PE OT LOC — <br />------ -- --- -- <br />$ —_ - -- <br />AUTOMOBILE LIABILITY <br />— <br />-- <br />COMBINED SINGLE LIMIT <br />Ea accident <br />$ 1,000,0001 <br />A <br />ANY AUTO <br />201221765NPO <br />10/1/2012 <br />10/1/2013 <br />BODILY INJURY (Per person) <br />$ <br />_ <br />ALL OWNED j SCHEDULED <br />—� AUTOS I -__ i AUTOS <br />I <br />BODILY INJURY (Per accident) <br />$ <br />I X� HIRED AUTOS X ED <br />L AUTOS <br />PROPERTY OAMAGE <br />$ -- - -� <br />— <br />Per accident <br />- <br />—I <br />I <br />- <br />UMBRELLA LIAB OCCUR <br />EXCESS LIAR <br />EACH OCCURRENCE <br />$ <br />AGGREGATE <br />$ <br />CLAIMS -MADE <br />DED RETENTION s <br />$ <br />_ <br />WORKERS COMPENSATION <br />WC STATU- OTH- <br />B <br />AND EMPLOYERS' LIABILITY Y / N <br />TORY LIMITS ER <br />E.L. EACH ACCIDENT <br />$ 1,000,000 <br />ANY PROPRIETOR /PARTNER /EXECUTIVE <br />OFFICER /MEMBER EXCLUDED? ❑ <br />NIA <br />WC201100000404 <br />10126/2011 <br />10/2612012 <br />— <br />E.L DISEASE -EA EMPLOYEE <br />_ <br />$ 1,000,000 <br />(Mandatory in and <br />If yes, describe under <br />E.L. DISEASE - POLICY LIMIT <br />$ 1,000,000 <br />_ <br />DESCRIPTION OF OPERATIONS below <br />A <br />I <br />ABUSE <br />201221765NPO <br />10/1/2012 <br />10/1/2013 <br />Occurence /Aggregate 1,000,000 <br />UtSCRIP r1ON 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 the attached CG 2026 endorsement. Such insurance is primary d.SjL <br />non - contributory per the attached endorsement. ((��,115� <br />ICATE HOLDER <br />ANCELLATION <br />��ROVVID <br />AS S� <br />S o cy`, <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANC ELLE BE ORE I <br />The City of Santa Ana THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELI ERED IN <br />20 Civic Center Plaza I <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />Santa Ana, CA 92702 <br />AUTHORIZED REPRESENTATIVE <br />I <br />©1988 -2010 ACORD CORPORATION. All rights reserved. <br />ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD <br />