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.—anti <br />, 2?Rt CERTIFICATE OF LIABILITY INSURANCE <br />1 DATE (MMA)D <br />10/16/201Y4 <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), AUTHOR1290 <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 the <br />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 Sariah Devereaux, Agent <br />1202 W 1st St <br />Sfate&rm Santa Ana, CA 92703 <br />a <br />CA ACT <br />NAME: Sariah Devereaux <br />HC.ONE E$g• 714-541=7280 I c no 17" 4-3e4-Jess <br />_ <br />ess: sarlah.dovereaux,tSlb( atatelamr,com <br />INSUAGR(S AFFORDING COVERAGE <br />NAIC# <br />INSURER A: State Farm Geneml Insurance Companyg1g <br />INSURED Cados Madriles <br />DBA Downtown Stadium Grill <br />602 N Flower St, Santa Ana, CA 02703 <br />INSURER e: � <br />wsuRERD: <br />INSURER D: <br />Ell <br />INSURER E; <br />INSURER P: <br />NHMRpO• <br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD <br />INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT MATH RESPECT TO MICH THIS <br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, <br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE OEEN REDUCED BY PAID CLAIMS. <br />Ina <br />TYPE OF INSURANCE <br />INSR1WVQ <br />POLICYNUMBER <br />0lrEY11 <br />PS�aD�pA'WV <br />LIMITS <br />A <br />GENERAL LIABILITY <br />X XOMMERCIALOENERALLIABIUTY <br />CLAIM&MADE❑OCCUR <br />_ <br />Y <br />92-C4-F307-T <br />0912912014 <br />0912912016 <br />EACH OCCURRENCE <br />$ 1,00D,000 <br />CAMAOT TORENTEO—"""'� <br />PREMISES Ba eo urrBnce <br />$ 300,000 <br />MEOEXP(Anymnpmaron) <br />PERSONAI. S ADV INJURY <br />§ 1,000,00(1 <br />GENERAL AGGREGATE <br />$ 2,000,000 <br />GEML AGGREGATE LIMITAPPLIES PER: <br />POLICY F7 Pas LOC <br />PRODUCTS-COMPIOP AGO <br />S 2,000,000 <br />Business Property <br />$ 26,000 <br />AUTOMOBILE <br />LIABILITY <br />ANYAUTO <br />AUTOS AUTOSCHS <br />HIRED AUTOAUTOSD <br />OaBWED O LIMIT <br />$ <br />BODILY INJURY (Per person) <br />$ <br />BODILYBODILY INJURY (Per accident) <br />S <br />PRe <br />rI5ERr7)_. <br />$ <br />S <br />UMBRELLA LIAB <br />EXCESS LIAB <br />OCCUR <br />CLAIM&MADE <br />EACH OCCURRENCE <br />$ <br />AGGREGATE <br />$ <br />DED RETEM'ION$ <br />_ <br />g <br />WORKERS COMPENSATION <br />AND EMPLOYERS' LIABILITY YIN <br />ANY PROPRIETOWARTNERIEXECUTNE <br />OFFICEIMEMSER EXCLUDED? <br />(Mandatory In NH) <br />yyee,dosndbeunder <br />NIA <br />❑ <br />WC BTq�U• OT <br />bRY LD& <br />. <br />E.LEACH ACCIDENT <br />$ <br />E,L. DISEASE -EA EMPLOYEE <br />$ <br />E.L. DISEASE- POLICY LIMIT <br />$ <br />DG4CRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (AHash ACORD 101, Additional Remarks Sosndutq R more space Is reaufmd) <br />Certificate holder, ire officers, agents, and employees are named as Additional Iltsured in regards to General Liability. <br />a30 days notice of cancellation for nonpayment. <br />Additional insured: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES DE CANCELLED BEFORE <br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />City of Santa Ana, its officers, employees, agents, and ACCORDANCE WITH THE POLICY PROVISIONS. <br />representatives <br />AUTHORIZED RBPRESENTATIVB <br />Pt) Box 1868 Santa Ana, CA 92702 <br />ID 1 S - 0 ACORD CORPORATION. All rights reserved. <br />ACORD 28 (2010105) The ACORD name and logo are registered marks f ACORD 1001486 132849.8 01.23.2013 <br />101V-Illy <br />