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7err' F.
<br />MERCY -2 OF ID: SO
<br />Ate R °' CERTIFICATE OF LIABILITY INSURANCE
<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 />DATE 0510 112 0 1 4 ?)
<br />0510112014
<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 endorsement(s).
<br />PRODUCER
<br />Dufour Insurance Services, LLC
<br />5811 Littler Drive
<br />ONTACT
<br />NAME: Stephanie Dufour
<br />PR °NE .714. 369.2998 nlc Na:714.840 -6357
<br />aooa[ess: Stephanie@dufourinsurance.com
<br />Huntington Beach, CA 92649
<br />Stephanie Dufour
<br />INSURER(S) AFFORDING COVERAGE
<br />NAIC iI
<br />INSURER A: Travelers Indemnity Company
<br />002517
<br />—'_
<br />:riI D PREMISES Ea occarenceL_
<br />INSURED Mercy House Living Centers Inc
<br />INSURERS: Travedws Property Casualt
<br />X COMMERCIAL GENERAL LIABILITY
<br />P.O. Box 1905
<br />Santa Ana, CA 92702
<br />INSURER c: Travelers Indemnit Com an
<br />002517
<br />0510212014
<br />05102!2015
<br />INSURER D:
<br />INSURER E : _
<br />INSURER F:
<br />MED EXP(My are 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, 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 />R
<br />TYPE OF INSURANCE
<br />L
<br />POLICY NUMBER
<br />M UD E F
<br />P LO
<br />LIMITS
<br />GENERAL LIABILITY
<br />EACH OCCURRENCE
<br />$ 1,000,00
<br />—'_
<br />:riI D PREMISES Ea occarenceL_
<br />$ 100,00
<br />A
<br />X COMMERCIAL GENERAL LIABILITY
<br />X
<br />8808802700914
<br />0510212014
<br />05102!2015
<br />CLAIMS -MADE aOCCUR
<br />MED EXP(My are person)
<br />$ 10,000
<br />PERSONAL &ADV INJURY
<br />$ 1,000,00
<br />GENERAL AGGREGATE
<br />$ 2,000,00
<br />GEN'L AGGREGATE
<br />LIMIT APPLIES PER:
<br />PRODUCTS - COMPIOP AGO
<br />$ 2,000,00
<br />Ded: $0
<br />$
<br />X1 POLICY
<br />PR LOG
<br />AUTOMOBILE LIABILITY
<br />Ea ac [dent SINGLE LI T
<br />S 1,000,00
<br />BODILY INJURY (Per person)
<br />$
<br />A
<br />ANY AUTO
<br />X
<br />BA8804667514
<br />05/0212014
<br />0510212015
<br />ALL OWNED SCHEDULED
<br />AUTOS X AUTOS
<br />X HIRED AUTOS X NON -OWNED
<br />AUTOS
<br />BODILY INJURY (Per accideml)
<br />$
<br />PROPERTY DAMAGE
<br />EggA (DENT
<br />$ 50,000
<br />Dad- $50031000
<br />$
<br />J(
<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 />CLAIMS -MADE
<br />CUP3909T12014
<br />05102/2014
<br />05102/2015
<br />DEO X RETENTION$ 10006
<br />$
<br />WORKERS COMPENSATION
<br />X WC STATU- OTH-
<br />B
<br />AND EMP40YERS' LIABILITY
<br />ANY PROPRIETOWPARTNERIEXECUTIVE Yn
<br />OFNCERIMEMBER EXCLUDED? L,.-I (Mandatory In NH)
<br />[NIA
<br />UB4216T17714
<br />0210812014
<br />02/08/2015
<br />EL EACH ACCIDENT
<br />$ 11000,00
<br />E.L. DISEASE -EA EMPLOYE
<br />$ 1,000,00
<br />D" yes, descre under DESCRIPTION OF OPERATIONS bebw
<br />EL. DISEASE- PDLICY LIMIT
<br />$ 1,000,00
<br />A
<br />Professional Liabi
<br />6608802700914
<br />05102/2014
<br />05/0212015
<br />Per Dec 1,000,00
<br />A
<br />Abuse Liability
<br />X
<br />6608802700914
<br />0510212014
<br />0510212015
<br />Aggregate 1,000,00
<br />DESCRIPTION OF OPERATIONS /LOCATIONS I VEHICLES (Attach ADDED 101, Addhirnal Remarks Schedule, IF more space Is regmired)
<br />Re: CDBG, ESG, and HPRP grants. City of Santa Ana, its officers, employees, �p
<br />agents, volunteers and representatives are named additional insureds with �T k� to w
<br />respect to the operations of the named insured G this policy is primary per
<br />the attached endorsement. Workes compensation coverage excluded, evidence
<br />only, 10 days notice of cancellation for non- payment of premium. L
<br />'LISA S• STpFtGK
<br />It AttarneY
<br />CERTIFICATE HOLDER
<br />CANCELLATION
<br />ACDRD 25 (2010105)
<br />©1988.2010 ACORD CORPORATION. All rights reserved.
<br />The ACDRD name and logo are registered marks of ACORD
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />i-.It Santa Ana
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />Y of
<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 />ACDRD 25 (2010105)
<br />©1988.2010 ACORD CORPORATION. All rights reserved.
<br />The ACDRD name and logo are registered marks of ACORD
<br />
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