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Client#: 758615
<br />THOMHOUS
<br />ACORD. CERTIFICATE OF LIA131LITY INSURANCE DATE (MMtDDNWY)
<br />01107112016
<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 />—TMPbM;A-Nf-- If the certificate holder Is an ADDITIONAL INSURED, the policy(les) 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 endorsementfs).
<br />PRODUCER
<br />INDICATED, NOTWTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
<br />UVRIA�l
<br />NAME: Terry Decker
<br />HUB Int'l Insurance Serv. Inc.
<br />INSR
<br />LTR
<br />PHONE
<br />C no, E.t): 714-922-4229 (AIC, L4SJ-L__
<br />License #0767776
<br />Vivo
<br />E-MAIL --- . .....
<br />ADDRESS. Cal.CPU@hLibinternational-com
<br />6701 Cantor Dr. West #1500
<br />POLICY Exe
<br />JktkILLPff YYY)_
<br />LIMITS
<br />A
<br />Los Angeles, CA 90046
<br />INSURER(S) AFFORDING COVERAGE
<br />NAtC P
<br />10103/2015101031201
<br />INSURERA: Great American Assurance Co.
<br />26344
<br />INSURED
<br />X CohWERC[ALGENFRALLIARILITY
<br />INSURERB:State 6—m—ponsatl 6"t -1 -111 s. Fund —
<br />—35067 6
<br />Thomas House Temporary Shelter
<br />ROMMElyer
<br />pL
<br />PO Box 2737
<br />INSURER C:
<br />Garden Grove, CA 92842
<br />MED EXP (Any one person)
<br />INSURER . D
<br />...... .......
<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, NOTWTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
<br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN tS SUBJECT TO ALL THE TERMS,
<br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAM CLAIMS.
<br />INSR
<br />LTR
<br />TYPE OF INSURANCE
<br />DLSUBR
<br />IN
<br />Vivo
<br />POLICY 1,4 ER
<br />POLICY EFF
<br />(MMJDDTn
<br />POLICY Exe
<br />JktkILLPff YYY)_
<br />LIMITS
<br />A
<br />GENERAL LIABILITY
<br />PAC0594539
<br />10103/2015101031201
<br />EACH OCCURRENCE
<br />$1 000
<br />X CohWERC[ALGENFRALLIARILITY
<br />ROMMElyer
<br />pL
<br />1100,000
<br />CLAIMS-MAOE F;A
<br />I At OCCUR
<br />MED EXP (Any one person)
<br />$5'000
<br />_tERSqNAL& kl5V INJURY
<br />$1,000,000
<br />................
<br />H--Nr-.RAI. AGGREGATE
<br />2,000,000
<br />GEN'L G(GRF(3ATE IMITAPPLISSPER:
<br />PRODUCTS-COMPiOPAGG
<br />$2,000,000
<br />POLICY [—] PRo-
<br />JECT LOG F-1
<br />$
<br />A
<br />AUTOMOBILE
<br />LIABILITY
<br />PAC0594539
<br />1010312015
<br />101031201C
<br />jEaaNdeinkl
<br />$1,000,000
<br />BODILY INJURY (Per person)
<br />$
<br />ANY AUTO
<br />ALL OWNED SCHEDULED
<br />AUTOS AUTOS
<br />BODILY INJURY (Par accident)
<br />$
<br />X
<br />NON,OWW'D
<br />JX
<br />PROPERTY DAMAGE
<br />$
<br />HIREDAUTOS AUTOS
<br />(Peraccident)
<br />............
<br />— ""
<br />UMBRELLA OUR
<br />R
<br />EACH OCCURRENCE
<br />S
<br />EXCESS LIAR CLAI 'MAII
<br />AGGREGATE
<br />I I RETENTIONS
<br />B
<br />WORKERS COMPENSATION
<br />488156615
<br />.
<br />. ....... — —
<br />10101/2016
<br />WO STATLI-
<br />X ITO RYLIMITS IER
<br />AND EMPLOYERS' LIABILITY YIN
<br />ANY PROPRIETORIPARTNERiEXECU7NE
<br />OFFICERA.'IEMBER EXCLUDED? ❑
<br />NIA
<br />ACCiQENT
<br />81,000,000
<br />_LL.EACH
<br />E.1- DISEASE • EA EMPLOYEE
<br />$1,000,000
<br />(Mandatory In NH)
<br />If yes describe under
<br />0, SCRIPTION OF OPERATIONS bellow
<br />.. ........
<br />1 1-. DISEASE - POLICY LIMIT $1,000,000
<br />. ....... ..
<br />DESCRIPTION OF OPERATIONS I LOCATIONS IVEHICLES (Attach ACORD 101, Additional Remarks Schedule,, If more space Is reqVired)
<br />City of Santa Ana, its officers, officials, agents, and employees are additiona I insured In regard to
<br />General Liability per attached form CG8224 12101.
<br />J
<br />City of Santa Ana
<br />Attn: Terri Eggars
<br />20 Civic Center Plaza
<br />Santa Ana, CA 92,701
<br />ACORD 25 (2010105) 1 Of
<br />#S3702717IM3702713
<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 />@ 1988-20I4 ACORD CORPORATION, ALI rights reserved,
<br />The ACORD name and logo are registered marks of ACORD
<br />TD41
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