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OP 1D: MB
<br />a►coRO CERTIFICATE OF LIABILITY INSURANCE DAT81031201155
<br />08/03/2
<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 INSURERIS), AUTHORIZED
<br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
<br />IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the poflcy(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 dau of such endorsementisi.
<br />PRODUCER "Amer.'
<br />NAME: MIS BUSK
<br />Brown &Brown of Florida, Inc. PHONE 813 2FAX
<br />P. o. Box 173086 .(Alc, ltg, Evil 81- -- _ _ -26.1337 _,.. EMAIL IAic, N.1) 813-226.1313
<br />...._� )
<br />Pampa, FL 53672 ADDRESS mbush_@Iqtampa.com
<br />Joseph W. Lo Presti PRODUCER ...... -- - --
<br />INSURED
<br />Holland & Knight Charitable INsuaEa e: Sentry Insurance
<br />Foundation Inc. _._......`— --
<br />100NorthTampaStreetSt4100 u+suaaac:Fed.—. Co/L _ Ins Und
<br />_ X --
<br />Tampa, FL 33602 INSURER D; Great Northern insurance.,
<br />rnVFRA(-.F9 CFRTIFICATF NI IMRFR• oFSAetn Al Aumaceo.
<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
<br />ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
<br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED
<br />BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL
<br />THE TERMS,
<br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />(NSR
<br />TYPE OF INSURANCE oCL1POLICY NUMBER
<br />fMM0DaYYYYI LIMITS
<br />GENERAL LABILITY
<br />I EACHOCCURRENCE S
<br />1,000,00
<br />D X COMMEROAL GENERAL Ias:u?v X35798711
<br />_ :
<br />' DAMAGE TOREN, 7w
<br />0810172016 08101@0161 PREMISES IEa o¢i rte b__
<br />—
<br />_1,000,00
<br />CLAIMSMADE X OCCUR :
<br />MEDE%PAn n
<br />�- I Yoe ,. - P c) 1 5
<br />10,0
<br />X Insured Contract
<br />j PERSONAL&AOV INJURY S
<br />1,900,OOD
<br />kGENERALAGGREGAIL S
<br />2,000,00
<br />GEN'LAGGREGATE LIMIT APPLES PER
<br />.....�
<br />I PRODUCTS - COMPIOPAGG S
<br />Included
<br />POLC/ : PRO- X : LOC
<br />AUTOMOBILE LIABILITY
<br />COMBINED SINGLE LIMIT
<br />'(Ee S
<br />1,000,00
<br />D X AUTO74886035
<br />amldenp
<br />0810172015 08101/2016 ...._._..—
<br />_
<br />1ANY.—
<br />BODILY NJURYfPttp rsnn) S
<br />OO� 1
<br />'
<br />BODILY NJURY(Peracc tlenn, s
<br />._._.._.
<br />BCHEDULEOAUTOSPRO
<br />X HIREDAUTOS :.
<br />-- MAGE I
<br />DAMAGE 1S
<br />'. (PER ACCIDENT)
<br />(PER ACCIDENT)
<br />---_
<br />NON OVMEDAUTOB
<br />1 ,---
<br />X No Owned Autos
<br />5
<br />--
<br />UMBRELLA LIAB X 1 OCCUR
<br />j EACHOCCURPENCE $
<br />49,000,000
<br />EXCESS LIAR CLAIMSMADE
<br />C -`- - -- 798183557101)0053016-03
<br />_.—
<br />' AGGREGATE 5
<br />08701/2015 08101/2016 F— REGATE ---
<br />.._.—
<br />49,000,00
<br />--..—
<br />LJ DEDucnBLE I
<br />I S
<br />.___... ..�...
<br />_.._
<br />RETENTION 5WORKERS
<br />i
<br />15
<br />NSATION I
<br />ERSELIABILIITY
<br />X YSAMSS- ER
<br />AND EMPLO VIN
<br />B ANY PROPRIETOPoPARTNENEXECPRVE 90149230119014920302
<br />OFFICEPoUEMBER EXCLUDED? NIA;l
<br />TR --
<br />08/01/201510810112016 L EL EACHACCIDENT S
<br />�—
<br />1,000,00
<br />IManddtarYlnNN)
<br />I fEL DISEASE - CA EMPLOYE S
<br />1,000,00
<br />u yae deacMee ander I
<br />: - -
<br />iDESCRRT10VDFOPERATONSh0a,v
<br />I LEL DISEASE -POLICY LIMIT 5
<br />1,D00,00
<br />D (Personal Property 35798711
<br />0810112015 081101;2016 !spec.Form
<br />116,079,000
<br />135798711
<br />D Data Proceas.Equip
<br />08!0112015 0810112016 fSpec.Form `rl }
<br />11,116,000
<br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORO 101, Additional RelnarRe Soh dula, it more space Ia required)
<br />See "Certificate Attachment - Holland S Knight, LLP dated B-1-15" attached.
<br />'y]
<br />CITYSAN
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />City of Santa Ana
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />David Cavazos, City Manager
<br />AUTHORIZED REPRESENTATIVE
<br />20 Civic Center Plaza
<br />Santa Ana, CA 92701
<br />W Ieee-LUUC AUUKU UUKPUKAI BUN. All rights reserved.
<br />ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD
<br />
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