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CERTIFICATE OF LIABILITY INSURANCEINSURANCEDATE
<br />(MMIDD
<br />3/2/2016JY'YYYj
<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 />CONTACT JoAnn Meyer
<br />Lake Insurance Agency
<br />653 South. B Street, Suite 2.00
<br />PHONE Extt: (714)263-3600' _ . ar No): (74Y 838-7568
<br />E-MAIL
<br />.ADDRESS: aann@lakeins.cam
<br />.__®.
<br />INSUR
<br />..EBJSJ AFFORDING COVERAGE ..._.._._ NAIC
<br />Lic #0747473
<br />INSURERA:Philadelphia Ind. Ins. Co.
<br />Tustin CA 92780
<br />INSURED
<br />INSURER B:State Comm ensation Insurance 35076
<br />_ .
<br />The Cambodian Family
<br />INSURER C!
<br />INSURER D: _
<br />1626 E. 4th Street
<br />INSURER E
<br />INSURER F.
<br />Santa Ana CA 92701
<br />COVERAGES CERTIFICATE NUMBER:16-1.7 PKG WC tfMB 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 />..
<br />)NSR.
<br />LTR
<br />TYPE OF INSURANCE
<br />ADDL
<br />INSQ
<br />SUBR
<br />WVQ
<br />_....
<br />POLICY NUMBER
<br />POLICY l=FF
<br />MMIDD/YYYY
<br />POLICY EXP
<br />MM1DDIYYYY
<br />-
<br />LIMITS
<br />X COMMERCIAL GENERAL LIABILITY
<br />,EACH OCCURRENCE l,OQQ,000
<br />A
<br />CLAIMS -MADE X OCCUR
<br />DAMAGE TO RFNTED PREMISES Ea occurrence)_ $ 100,000
<br />�..
<br />X
<br />PHPK1461345
<br />3/9/2'016
<br />3/9/2017
<br />MED EXP (Anyone person) $... 5,000
<br />''...PERSONAL SADV INJURY $ 1,000,000
<br />GEN'L AGGREGATE LIMIT APPLIES PER:
<br />GENERAL AGGREGATE. $3,000,000
<br />POLICY JECCIT LOC
<br />PRODUCTS - COMP(OP AGG $ .r. 1,000,000
<br />Abuse/Molestation Agg. $ 1,000,000
<br />OTHER:
<br />I
<br />..AUTOMOBILE
<br />LIABILITY
<br />'COMaccident.BINED SINGLE LIMIT... $
<br />Ea
<br />BODILY INJURY (Per person) $
<br />A
<br />_
<br />ANY AUTO
<br />_R .�.....
<br />BODILYnNJUJURY(Per accident)
<br />ALL OWNED SCHEDULED
<br />AUTOS AUTOS
<br />PHPK1461345
<br />3/9/2016
<br />3/9/2017
<br />X
<br />HIRED AUTOS X NON -OWNED
<br />AUTOS
<br />PROPERTY DAMAGE $
<br />Per accident
<br />Nan -owned $ 1,000,000
<br />X
<br />UMBRELLA LIAR
<br />OCCUR
<br />EACH OCCURRENCE $ 1 000 000
<br />AGGREGATE $ 1 000 000
<br />A
<br />EXCESS LIAR
<br />Gl.slkMS-MADE
<br />DFD X RETENTION $ 10,000
<br />$
<br />PRLT8532093
<br />3/9/2016
<br />3/9/2017
<br />WORKERS COMPENSATION
<br />X. STATUTE OETRH
<br />AND EMPLOYERS' LIABILITY YIN
<br />E.L. EACH ACCIDENT $ 1 000 QQQ...
<br />ANY PROPRIETORIPARTNER/EXECUTIVE
<br />OFFCF.RfMEMBER EXCLUDED?
<br />N d A
<br />.........
<br />(Mandatory In NHI
<br />906498615
<br />6../30/2015
<br />6/30/2.016
<br />E.L DISEASE -EA EMPLOYE. $ 1,000,000
<br />It yes, describe under
<br />___ ....._._._._.
<br />DESCRIPTION OF OPERATIONS below
<br />I
<br />I
<br />E.L. DISEASE - POLICY LIMIT $ 1,000,000
<br />A
<br />Professional Liability
<br />PH1K1461345
<br />3/9/2016
<br />3/9/2017
<br />1,000,000
<br />Sexual or Physical Abuse
<br />1,000,000
<br />DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required)
<br />City of Santa Ana, Officers, Employees, Agents, Volunteers and Representatives as Additional Insured,
<br />Primary applies under General Liability per policy form as required by written contract with Named
<br />Insured.
<br />Endorsement to fallow from carrier.
<br />57^
<br />CERTIFICATE HOLDER CANCELLATION
<br />City of Santa Ana
<br />Officers, Employees, Agents,
<br />Volunteers and Representatives
<br />20 Civic Center Plaza, M-25
<br />Santa Ana, CA 92701
<br />ACORD 25 (2014101)
<br />INS025 r?nwall
<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 RE'PRESENTATI'VE
<br />Rob Lake/,JOANNM
<br />U 1988-2014 ACORD CORPORATION. All rights reserved.
<br />The ACORD name and logo are registered marks of ACORD
<br />
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