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ACOR4 m CERTIFICATE OF LIABILITY INSURANCE 1 u " ""`7iz" m ""
<br />i n ian
<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 ,,,r.7,
<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. Al j
<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 />Mutual Insurance Agency
<br />CA License # 0574081
<br />30 N. Marengo Ave
<br />Pasadena, CA 91101
<br />CONTACT
<br />NAME:
<br />PHONE 626.795.9595 FAX 626.793.7864
<br />AIC Na Ext: AIX No
<br />E -MAIL
<br />ADDRESS:
<br />INSURER(S) AFFORDING COVERAGE
<br />NAIC#
<br />INSURERA: American States Ins Co
<br />19704
<br />INSURED MDG Associates, Inc.
<br />10722 Arrow Route, Suite 822
<br />Rancho Cucamonga, CA 91730
<br />INSURER B:
<br />INSURER C:
<br />INSURER 0:
<br />01CH067149900710112013
<br />INSURER E:
<br />07/01/2014
<br />INSURER F:
<br />$ 1,000 000
<br />I UVCKAUca UCKIIrIGAIL NUIVICCK: LUl5 -ZLI UL. AUTO. Um0 HFVISKIN NHMFi
<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 />INTRR
<br />TYPE OF INSURANCE
<br />ADDLSUBR
<br />POLICY NUMBER
<br />MM/DD /YVYV
<br />MMIDD /YVYV
<br />LIMITS
<br />GENERAL LIABILITY
<br />01CH067149900710112013
<br />07/01/2014
<br />EACH OCCURRENCE
<br />$ 1,000 000
<br />X COMMERCIAL GENERAL LIABILITY
<br />CLAIMS -MADE OCCUR
<br />PREMISES (Ea occurrence
<br />$ 200,000
<br />MED EXP(Any one person)
<br />$ 10,000
<br />A
<br />X
<br />PERSONAL id ADV INJURY
<br />$ 1,000,000
<br />GENERAL AGGREGATE
<br />$ 2,000,000
<br />GEH L AGGREGATE LIMIT APPLIES PER:
<br />PRODUCTS - COMP /OP AGO
<br />$ 2,000,000
<br />POLICY PRO-
<br />JECT LOC
<br />$
<br />AUTOMOBILE
<br />LIABILITY
<br />01CI]00]352
<br />07/01/2013
<br />07/01/2014
<br />(Ea accident)
<br />$ 1,000,000
<br />X
<br />SOD I LY NJURY(Par person)
<br />$
<br />ANY AUTO
<br />A
<br />ALL OWNED SCHEDULED
<br />AUTOS AUTOS
<br />X
<br />BODILY INJURY Per accident
<br />( )
<br />$
<br />HIRED AUTOS X AUTOSWNED
<br />X
<br />(Per accident)
<br />$
<br />UMBRELLA LIAR
<br />I X
<br />OCCUR
<br />01XS149917800710112013
<br />0710112014
<br />EACH OCCURRENCE
<br />$ 4,000,000
<br />X
<br />AGGREGATE
<br />$ 4,000,000
<br />A
<br />EXCESS LIAR
<br />CLAIMS -MADE
<br />X
<br />rcP+'
<br />OGD X RETENTION $ 10,000
<br />$
<br />WORKERS COMPENSATION
<br />ANDEMPLOYERS'LIABILITY VIN
<br />ANY PER/MEMB RIPARTNE ED'? UTIV�
<br />EMBER EXCLUDED?
<br />NIA
<br />y� {,
<br />y y-!J jn'a�
<br />�( l) RL�
<br />ia�
<br />"�r.ry'
<br />,.-' ✓'
<br />~ -
<br />-
<br />WCSTAi OTH
<br />TORY LIMITS ER
<br />EL. EACH ACCIDENT
<br />$
<br />E. L, DISEASE - EA EMPLOYE
<br />$
<br />(Mandatory
<br />(f yes, d ory in NH)
<br />describe under
<br />(� r..
<br />���
<br />-_^ 'y
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<br />EL DISEASE - POLICY LIMIT
<br />$
<br />Dyes,
<br />DESCRIPTION OF OPERATIONS below
<br />,.. --'c: �,
<br />�e
<br />Assistant C
<br />ry
<br />DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required)
<br />The City of Santa Ana, its officers, employees, agents and volunteers are named Additional Insured,
<br />but only as respects the Insureds Operations as it relates to their Signed Contract in regards to the
<br />CDBG Administration Consulting Services per Form CG8674 attached. Primary Insurance and
<br />Transfer of Rights of Recovery Against Others is included per Form C00001 attached.
<br />CERTIFICATE HOLDER CANCELLATION
<br />City of Santa Ana
<br />Community Development Agency
<br />Attn: Terri Eggers, Senior Mgmt. Analyst
<br />20 Civic Center Plaza
<br />Santa Ana, CA 92701
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />AUTHORIZED REPRESENTATIVE
<br />Paul
<br />ACORD
<br />ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD
<br />
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