|
In i
<br />CERTIFICATE LIABILITYINSURANCE DAM
<br />9R i r
<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(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
<br />certificate holder In lieu of such endorsement(s).
<br />PRODUCER ICONTANAME ERIKA STEWART
<br />TERRY BRADSHAW,
<br />• BLVD., SUITE 207
<br />_*1 VILLA PARK, CA •..
<br />Q
<br />INSURED
<br />r
<br />a%. - i y.
<br />a a
<br />CERTIFICATE NUMBER -
<br />PHONE FAX
<br />, ,714-637-4120 fAIC Ne.714-637-4260
<br />MAIL s. ERIKA.STEWART.T280(&STATEFARM.COM
<br />L'AIL
<br />B:
<br />INSURER D
<br />INSURER(S) AFFORDING COVERAGE I NAIC 4
<br />Farm Fire and Casualty Company 1 25143
<br />FrATiLqr*71Tff YnTFIETETR
<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 />-.,_ "-'�"�"
<br />TYPE OF INSURANCE
<br />IttIOL
<br />INSO
<br />SUB R
<br />WVD
<br />POLICY NUMBER
<br />POLICY EFF
<br />(MMIDDNYYYI
<br />POLICY EXP
<br />JMMLQROrrm
<br />LIMITS
<br />A
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />Y
<br />EACH OCCURRENCE
<br />$ 1,000,000
<br />CLAIMS -MADE 1 " I OCCUR
<br />PREMISES Ea oodurcenca
<br />S 300,000
<br />MED EXP (Any one person)
<br />S
<br />92-CZ-W382.6
<br />OW1612014
<br />05/1612015
<br />PERSONAL & ADV INJURY
<br />�v5,000
<br />$ 1,000,000
<br />GEN'L AGGREGATE LIMIT APPLIES PER:
<br />% POLICY E JEa D LOC
<br />GENERAL AGGREGATE
<br />$ 2,000,000
<br />PRODUCTS, COMP/OP AGG
<br />$ 2,000,000
<br />$
<br />_ OTHER:
<br />B
<br />AUTOMOBILE
<br />LIABILITY
<br />COMBINED SINGLE LIMIT
<br />Ea aidenfl
<br />$ ' 004 000
<br />BODILY INJURY (Per person)
<br />$
<br />ANY AUTO
<br />471 7092-E19-75
<br />11/1912014
<br />05/1912015
<br />Ix
<br />ALL OWNED SCHEDULED
<br />AUTOS AUTOS
<br />BOOILYINJURY(Peracctdert)
<br />$
<br />x NOWOWNED
<br />HIRED AUTOS AUTOS
<br />---..
<br />PROPERTY DAMAGE
<br />(_AsreccddantL^_�.,-
<br />-----._�..._.._.-..._....__.-....__
<br />$
<br />$
<br />C
<br />X
<br />OMBRELLa Llae X
<br />OCCUR
<br />N
<br />92-CZ-W386-5
<br />05/16/2014
<br />05/1612015
<br />EACH OCCURRENCE
<br />$ 2,000,000
<br />AGGREGATE
<br />$ 2,000,000
<br />EXCESS LIAR
<br />CLAIMS -MADE
<br />DED RETENTION $
<br />$
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY Y 1 N
<br />ANY PROPRIETORIPARTNERIEXECUTIVE
<br />OFFICERIMEMBER EXCLUDED?
<br />(Mandatory In NH)
<br />If yes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />ENIA
<br />ER TH-
<br />...., STATUTE ER
<br />E T_ EACH ACCI DFNT
<br />$
<br />E.L. DISEASE - EA EMPLOYE'
<br />$
<br />E.L. DISEASE- POLICY LIMIT
<br />- —""-
<br />$
<br />DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES (ACORD 101, Addidonal Remarks Schedule, may he attached It more speae I$ requimd)
<br />GL ADDITIONAL INSURED AND PRIMARY AND NON-CONTRIBUTORY WORDING APPLIES PER THE STFESP101 ECW0910 ATTACHED AS REQUIRED
<br />BY WRITTEN CONTRACT. RE: OPERATIONS OF THE NAMED INSURED, ADDITIONAL INSURED(S): CITY OF SANTA ANA , IT'S OFFICERS, AGENTS,
<br />VOLUNTEERS AND EMPLOYEES,
<br />AGREEMENT NUMBERS:A-2006-046&A-2014-035 HENNE SSEY & HENNES` Ei.Y _L.C: AG-R# A- 006-046 & A-2014-035
<br />REVIEWED BY; �'r ,� ..m" EUNICE HERE. IA (PG. 1 of 5)
<br />CITY OF
<br />PUBLIC WORKS
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES 5.. CANCELLED BEFORE
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />ACCORDANCE WITH THE POLICY PROVISION$,
<br />aAUORIZEII "REPRESE1 TATIVE
<br />L, A
<br />,i PTAINI&F. F;"• +--.#,,
<br />•r
<br />
|