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ACCORZY CERTIFICATE OF LIABILITY INSURANCE DATE 15 8 13/2oI) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: JoAnn Meyer PHONE E (714)263-3600 A1C No: 1714)838-756B Lake Insurance Agency MAI 3 oann@lakeins.com ADD 653 South B Street, Suite 200 INSURER(S) AFFORDING COVERAGE NAICR Lio #0747473 INSURER A:Philadel hia Ind. Ins. Co. Tustin CA 92780 INSURED INSURERB:State Compensation Insurance 35076 INSURER C: The Cambodian Family INSURER D: 1626 E. 4th Street INSURER E PHPK1287400 INSURER F: Santa Ana CA 92701 COVERAGES CERTIFICATE NUMBER:15-16 All Lines REVISION NUMBER - THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR rypE OF INSURANCE AO DLSU BR POLICY NUMBER POLICY EFF MMIDDI1'YYY POLICY EXP MM DD LIMITS A X COMMERCIAL GENERAL LIABILITY1,000,000 CLAIMIOCCUR EACH OCCURRENCE $ DAMAGE TO RENTED 100,000 PREMISES Ea occurrence $ MED EXP (Any one person) $ 5,000 X PHPK1287400 3/9/2015 3/9/2016 PERSONAL &ADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 X POLICY PRO- LOC ECT PRODUCTS-COMPIOP AGO $ 1,000,000 Abuse/Molestation Agg. $ 1,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) $ A ANY AUTO AUTOSALL NEO SCHEDULED PHPK1287400 3/9/2015 3/9/2016 BODILY INJURY (Per accident) $ X HIRED AUTOS X NON -OWNED AUTOS PROPERTY DAMAGE $ Per accident Nan -owned $ 1,000,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DEO RETENTION $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNEWEXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under NIA 906498615 6/30/2015 6/30/2016 X PER OTH- STATUTE ER E.L. EACH ACCIDENT $ 11000,000 E. L. DISEASE - EA EMPLOYE $ 1 000 000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS below A Professional Liability PHPK12B7400 3/9/2015 3/9/2016 1,000,000 Sexual or Physical Abuse 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS IVEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) City of Santa Ana, Officers, Employees, Agents, Volunteers and Representatives as Additional Insured, Primary applies under General Liability as required by written contract with Named Insured. C V, F _. CERTIFICATE HOLDER CANCELLATION ACORD 25 25 (2014/01) IN S025 (201401) © 1988.2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City Of Santa Ana THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Officers, Employees, Agents, ACCORDANCE WITH THE POLICY PROVISIONS. Volunteers and Representatives AUTHORIZED REPRESENTATIVE 20 Civic Center Plaza, M-25 Santa Ana, CA 92701 ��- Rob Lake/JCANNM ACORD 25 25 (2014/01) IN S025 (201401) © 1988.2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD