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CERTIFICATE NO. <br />ISSUE DATE (MM /DD/YYYY) <br />WC -1682 <br />CERTIFICATE OF COVERAGE <br />10/15/2013 <br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO <br />CSAC Excess Insurance <br />RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AFFIRMATIVELY <br />OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BELOW. THIS <br />Authority <br />CERTIFICATE OF COVERAGE DOES NOT CONSTITITUE A CONTRACT BETWEEN THE <br />ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE <br />CERTIFICATE HOLDER <br />C/O ALLIANT INSURANCE SERVICES, INC. <br />IMPORTANT: If the certificate holder is requesting a WAIVER OF SUBROGATION, the <br />PO BOX 6450 <br />NEWPORT BEACH, CA 92658 -6450 <br />Memorandums of Coverage must be endorsed. A statement on this certificate does not confer <br />rights to the certificate holder in lieu of such endorsement (s). <br />PHONE (949) 756 -0271 / FAX (619) 699 -0901 <br />COVERAGE <br />LICENSE #OC36861 <br />AFFORDED BY: A - See attached Schedule of Insurers <br />Member: <br />COVERAGE <br />ORANGE COUNTY FIRE AUTHORITY <br />AFFORDED BY: B <br />ATTN: FAUSTO REYES, RISK MANAGER <br />COVERAGE <br />1 FIRE AUTHORITY ROAD, BLDG A <br />IRVINE, CA 92602 <br />AFFORDED BY: C <br />F VERAGE <br />FORDED BY: D <br />Coverages <br />THIS rS TO CERTIFY THAT THE MEMORANDUMS OF COVERAGE AND POLICIES LISTED BELOW HAVE BEEN ISSUED TO THE MEMBER <br />NAMED ABOVE FOR THE PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR <br />OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE COVERAGE AFFORDED BY <br />THE MEMORANDUMS AND POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS, AND CONDITIONS OF SUCH <br />MEMORANDUMS AND POLICIES. <br />CO <br />TYPE OF COVERAGE <br />MEMORANDUM/ <br />COVERAGE EFFECTIVE <br />COVERAGE EXPIRATION <br />LIABILITY LIMITS <br />LTR <br />POLICY NUMBER <br />DATE(MM /DD(YYYY) <br />DATE(MM /DDM'YY) <br />A <br />EXCESS WORKERS' <br />See attached <br />07/01/2013 <br />07/01/2014 <br />WORKERS'COMPENSATION: <br />COMPENSATION & <br />Schedule of Insurers <br />Difference between <br />EMPLOYER'S LIABILITY <br />for policy numbers <br />Statutory and Member's <br />$2,000,000 Retention <br />EMPLOYERS' LIABILITY: <br />Difference between <br />$5,000,000 and Member's <br />$2,000,000 Retention <br />LIMITS APPLY PER OCCURRENCE FOR ALL PROGRAM MEMBERS COMBINED. <br />Description of Operations /LocationsNehicles /Special Items: <br />AS RESPECTS EVIDENCE OF COVERAGE FOR AGREEMENT BETWEEN ORANGE COUNTY FIRE AUTHORITY AND CITY OF SANTA ANA. <br />AS TO FORM <br />A. <br />"aura A. Rossini <br />,f ^ir1 City Attorney <br />Certificate Holder <br />Cancellation <br />SHOULD ANY OF THE ABOVE DESCRIBED MEMORANDUMS OF COVERAGE/POLICIES BE <br />CITY OF SANTA ANA <br />CANCELLED BEFORE THE EXPIRATION THEREOF, NOTICE WILL BE DELIVERED IN <br />ATTN: LAURA ROSSINI <br />ACCORDANCE WITH THE MEMORANDUMS OF COVERAGE/POLICIES PROVISIONS. <br />SENIOR ASSISTANT CITY ATTORNEY <br />AUTHORIZED REPRESENTATIVE <br />20 CIVIC CENTER PLAZA, M29 <br />SANTA ANA, CA 92702 <br />CSAC EXCESS INSURANCE AUTHORITY <br />Page 1 of 2 <br />