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i-, MERCY -2 OP ID: SD
<br />,4coRO° CERTIFICATE OF LIABILITY INSURANCE
<br />`....--�
<br />DATE10812013
<br />05/08/2013
<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 endomement(s).
<br />PRODUCER Phone: 714 - 369 -2998
<br />Dufour Insurance Services, LLC
<br />5611 Littler Drive Fax: 714- 840 -6357
<br />CONTACT NAME Stephanie DUfOUf
<br />(PHcc "N E,),714- 369 -2998 alc Nq:I74- 8_40 -6357
<br />E -MAIL
<br />ADDRESS: Ste hanie dufourinsurance.c_o_m
<br />Huntington Beach, CA 92649
<br />Stephanie Dufour
<br />_ -_
<br />INSURER(S) AFFORDING COVERAGE
<br />NAIC9 _
<br />INSURER A: Travelers Property Casualty
<br />$ 1,000,00
<br />�G6
<br />PREMISES Ea occurrence
<br />INSURED Mercy House Living Centers Inc
<br />INSURERS: Seabrlght Insurance Company
<br />15563
<br />P.O. Box 1905
<br />Santa Ana, CA 92702
<br />-
<br />INSURER c: Travelers Indemnity Company
<br />_-
<br />06/0212013
<br />_
<br />INSURER D:
<br />INSURER E:
<br />INSURER F:
<br />MED EXP(Any one person)
<br />$ 10,000
<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. NOT VITHSTANDING 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 />Frank Hernandez
<br />POLICY NUMBER
<br />POLICY EFF
<br />MMIDDIYYVY
<br />POLICY EXP
<br />M IY
<br />MIDDYYY
<br />LIMITS
<br />GENERAL LIABILITY
<br />EACH OCCURRENCE
<br />$ 1,000,00
<br />�G6
<br />PREMISES Ea occurrence
<br />$ 100,000
<br />A
<br />X COMMERCIAL GENERAL LIABILITY
<br />X
<br />6608802700913
<br />06/0212013
<br />05102/2014
<br />CLAIMS -MADE OCCUR
<br />MED EXP(Any one person)
<br />$ 10,000
<br />PERSONAL B ADV INJURY
<br />I$ 1,000,000
<br />GENERAL AGGREGATE
<br />S 2,000,00
<br />GEN1 AGGREGATE LIMIT APPLIES PER.
<br />PRODUCTS - COMPIOP AGG
<br />$ 2,000,00
<br />Ded: $0
<br />$
<br />PRO-LOG
<br />X POLICY JECT
<br />I
<br />AUTOMOBILE LIABILITY
<br />~'i
<br />COMBINED SINGLE LIMIT
<br />(Ea accident) _
<br />1,000,00
<br />$ _
<br />1 BODILY INJURY (Per person)
<br />S
<br />A
<br />ANY AUTO I
<br />X
<br />BABB04667613 0510212013
<br />05102/2014
<br />ti ALL OAMED X 1J SCHEDULED
<br />AUTOS AUTOS
<br />X HIRED AUTOS X NON -OMED
<br />AUTOS
<br />BODILY accidanq,S
<br />_
<br />PROPERTY DAMAGE
<br />Peraccident )
<br />!S 50,000
<br />Ded- $500 /$1000
<br />'S
<br />)(
<br />UMBRELLA LIAB
<br />X
<br />OCCUR
<br />EACH OCCURRENCE
<br />$ 4,000,00
<br />AGGREGATE
<br />$ 4,000,00
<br />C
<br />EXCESS LIAB
<br />Cl-AIMS-MADE
<br />X
<br />CUP3909T12013
<br />0510212013
<br />0510212014
<br />DED X' RETENTIONS 10000
<br />$
<br />B
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY
<br />ANY PROPRIETORIPARTNERIEXECUTIVE YIN
<br />OFFICERNEMBER EXCLUDED?
<br />'(Mandatory inNH)
<br />NIA
<br />BB1113517
<br />02108/2013
<br />0210812014
<br />X VvC STATU- OTH-
<br />LIMITS RY LIMIT ER
<br />EL. EACH ACCIDENT
<br />_
<br />$
<br />EL DISEASE - EA EMPLOYEES
<br />-
<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 />Professional Liabi
<br />X
<br />6608BO2700913
<br />05/02/2013
<br />0510212014
<br />Per Occ 1,000,00
<br />A
<br />Abuse Liability
<br />X
<br />6608802700913
<br />0510212013
<br />05102/2014
<br />Aggregate 1,0.00,00.
<br />1
<br />`-) r,
<br />DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) OZ
<br />Re: CDBG, HSG, and RPRP grants. City of Santa Ana, its officers, employees, V L
<br />IjYR.
<br />agents, volunteers and representatives are named additional insureds with
<br />respect h insured policy primary per
<br />� '�'JnGY•nEV
<br />the attached endorsement. Workes ompensationcoverageexcluded ,evadence
<br />only. 10 days notice of cancellation for non - payment of premium. US C` {v A�toC
<br />Ass {Stmt t/ �-
<br />CERTIFICATE HOLDER CANCELLATION
<br />©1988 -2010 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />City f Santa Ana
<br />tY
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />Frank Hernandez
<br />20 Civic Center Plaza Box 1988
<br />AUTHORIZED REPRESENTATIVE
<br />Santa Ana, CA 92702
<br />©1988 -2010 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD
<br />
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