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`° R" CERTIFICATE OF LIABILITYDATE (MM/201 YY)
<br />INSURANCE a9,29�2015
<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 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 CONTACT
<br />Sariah Deve reaux- Barrie ITtos, Agent NAME: Sariah Devereaux-Barriento5
<br />'PHONE
<br />:FAX W `st St No, Ext: 714-541-7280 IC, No);. 714-384-3892
<br />E-MAIL
<br />Staf,Far'm Santa Ana, CA 92703 ADDRESS: sartah.devereaux.t8lb@c taltefarm,com_
<br />INSURERS) AFFORDING COVERAGE NAIC lR..... ....
<br />INSURER A : State Farm General Insurance Company 25151
<br />INSURED Carlos. M.adriles INSURERS: _......
<br />DBA Downtown Stadium Grill INSURERC:
<br />602 N Flower St, Santa Ana, CA 92703 INSURER D _
<br />IdWSURER E
<br />Ww �. w. -
<br />INSURER F :
<br />COVFRAC,FS r`-FRTIFIr..ATI= NI IMRKR• aetricrnMr wl rnxrsree.
<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
<br />DOCUMENT WITH RESPECT TO WHICH THIS
<br />CERTIFICATE MAY BE ISSUED' OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED
<br />HEREIN IS SUBJECT TO
<br />ALL THE TERMS,
<br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
<br />INSR _ "ADDL SUBR......... ......... _. POLICY FEE ........POLICY EXP
<br />LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MMfDD/YYYY) fMMIDDIYYYYI
<br />_.. _...... __.
<br />LIMITS
<br />L LIABILITY L',
<br />A GENERAY 92-EDZ9660 09/2912015 05P2912016
<br />EACH OCCURRENCE
<br />$ 1,000,000
<br />,.. COMMERCIALDAMAGE
<br />GENERAL LIABILITY
<br />TO RENTEDI
<br />PREMISES (Ea occurrence)
<br />_,'. $ 300,000....
<br />....._.
<br />_ CLAIMS -MADE .... ., OCCUR
<br />MED EXP (Any one person)
<br />$ 5,000
<br />......... ......... _._ __. _.
<br />PERSONAL 3 ADV INJURY
<br />S 1,000,.000
<br />GENERAL AGGREGATE
<br />$ 2,000 000
<br />GEN"L AGGREGATE LIMIT APPLIES PER
<br />PRODUCTS - COMPIOP AGG
<br />S 2'.,000,000 _...
<br />POLICY PE C LOC
<br />Business Property
<br />S 25,000
<br />AUTOMOBILE LIABILITY
<br />COMBINED SINGLE LIMIT
<br />......._
<br />�:......
<br />(Ea accident)
<br />S ......... .............
<br />ANY AUTO
<br />BODILY INJURY (Per person)
<br />$
<br />ALLOWNEDDULEO
<br />AUTOS AUTO
<br />.. NON-GOWNEDN
<br />BODILY INJURY (Per accident)
<br />PROPERTY DAMAGE
<br />$
<br />HIREDAUTOS AUTOS a1,
<br />(Per awdem)
<br />$
<br />i�
<br />^C.d
<br />...
<br />_.
<br />III a
<br />S
<br />UMBRELLA LIAR OCCUR El 11. /' _�' �� ;.�fy �
<br />...
<br />EACH OCCURRENCE
<br />'S
<br />EXCESS LIAR CLAVMS-MADE ,^` "'..1
<br />AGGREGATE ..-.S
<br />S
<br />DED RETENTIONS
<br />WORKERS COMPENSATION' (*�
<br />AND EMPLOYERS' LIABILITY Y
<br />WC STATU- CTH-
<br />TORY LIMITS... ER
<br />Y 1 N f"" -
<br />ANY PROPRIE.TOR(PARTNERIEXECUTIVE -_- \„±
<br />OF'FICEIMEMBER EXCLUDED? NIA ,.....
<br />E L EACH ACCIDENT
<br />._..
<br />S
<br />(Mandatery in NH)
<br />E L. DISEASE - EA EMPLOYEE
<br />$
<br />It yes, describe under
<br />....
<br />__
<br />12ES R T ATIO b low
<br />E.L. DISEASE - POLICY LIMIT
<br />$
<br />DESCRIPTION OF OPERATIONS I LOCATIONS t VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
<br />Certificate holder, it's officers, agents, and employees are named as Additional Insured in regards to General Liability.
<br />*30 days notice of cancellation for nonpayment.
<br />- I " 1 g1/L.W"FN
<br />Additional Insured':
<br />City of Santa Ana, its officers, employees, agents, and
<br />representatives
<br />PO Box 1988 Santa Ana, CA 92702
<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 />Sariah Devereaux-Barrientos
<br />lNJ 5 dem 6 M S M. '"W10 r'arm, au
<br />bblalrzaM1 tleueran�ax f8lG�std'mlarrn cam,c us
<br />�t5.pp.24I©:SB:24.Qp"r'h3'
<br />O 1988 2010 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (20'10/05) The ACORD name and logo are registered marks of ACORD 1001486 132849.8 01-23-2013
<br />
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