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'M `..I <br />CERTIFICATE OF LIABILITY INSURANCE F10 5 4 <br />DA EPANI[/D[TYYY7) <br />177/2016 <br />THIS CERTIFICATEIS 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(ios) must be endorsed. If SUBROGATIONIS WAIVED, subject to the <br />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 />PROOUCER <br />13TH INSURANCE HOLDINGS LLC/PHS <br />CONTACT <br />NAME <br />PHONE <br />(NCN.,E.t$ (866) 467-873 <br />AX <br />4888) 443-6112 <br />505500 P: (866) 467-8730 F: Q888) 443-6112 <br />1"IAII <br />ADDRESS': <br />PO BOX 33015 <br />NSURERIS) AFFORDING COVERAGE NAIC# <br />SAN ANTONIO TX 78265 <br />INSURER A Semtinel TnS CO LTD <br />WSUREL) <br />INSURER B <br />INSURER C <br />HJELMSTROM & ASSOCIATES <br />INSURER D: <br />25072 WILKES P'L <br />INSURER E, <br />$1, coo, 000 <br />,LAGUNA HILLS CA 92653 <br />[INSURER I <br />UIDVI=KA(JI=5 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 />CERflFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE <br />TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POUCIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, <br />LTR <br />11TE OFINSVRANCE <br />ADDL <br />INSR <br />SUBI? <br />III"[) <br />POWTNUVIRER <br />P0LICYErF <br />1sollavlyyy9,i <br />11,117E4 <br />COMMERCIAL GENERAL LIABILITY <br />EACH OCCURRENCE <br />5.1 , 000, 000 <br />r 771 OCCUR <br />CLAIMS-MADE I I II <br />DAMAGE TO RENTE5 <br />REMISES (Ea OCCUrrence) <br />$1, coo, 000 <br />X <br />x <br />MED EXP (Any one person) <br />s101 000 <br />A <br />General Lial-7 <br />46 SBM um38(11 <br />04/16/2015 <br />04/16/2016 <br />PERSONAL A. ADV INJURY <br />I , 0 0 0 , 0100 <br />GEN'L <br />AGGREGATE LIMIT APPLIES PER <br />GENERAL AGGREGATE <br />2,000, 0100 <br />POLICY PRO- <br />JECT X LOC <br />PRODUCTS - CCMPfOP AGG <br />� 2 , 000, COO <br />OTHER: <br />AUTOMOBILE <br />LIABILITY <br />COMBINED SINGLE LIMIT <br />(Ea accident) <br />BODILY INJURY (Per person) <br />ANY AUTO <br />ALL OWNED ISCHEDULED <br />�AUTOS <br />BODILY INJURY (Per ­ddenl) <br />$ <br />NON-OWNED <br />i711UR;ODSAUTOS .'':AUTOS <br />PROPERTY DAMAGE <br />(Per accident) <br />UMBRELLA LIAB <br />OCCUR <br />EACH OCCURRENCE <br />EXCESS LIAB <br />CLAIMS -MADE <br />AGGREGATE <br />1011 1ETE11TI.N I. <br />WORKERS (Y)AIPENNA 174W <br />PER OTH_ <br />IND EMPLOFERYLIARILILY <br />AIIJT:1���El <br />E L. EACH ACCIDENT <br />ANY PROPRIETCRIPARTNERIEXECUTIVE YIN <br />OFHCERIMEMBER EXCLUDED? 7_1 <br />(Mandatory In Ni Li <br />NIA <br />E.L DISEASE- EA EMPLOYEE <br />if yes, describe Linder <br />DESCRIPTION OF OPERATIONS below <br />E.L. DISEASE <br />DESCRIPTION OF OPERATIONS I LOCATIONS/ VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) <br />Those usual to the Insured's Operations. Please see Additional Remarks <br />Schedule Acord Form 101 attached. <br />..... . ... ..... <br />REV�EWED BY <br />CERTIFICATE HOLDER CANCELLATION <br />Q9 1988-2014 ACORD CORPORATION, All rights reserved. <br />ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED <br />City of Santa Ana <br />BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE <br />DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. <br />AUTHORIZED REPRESENTATIVE <br />Attn: Purchasing Department <br />20 CTVTC CENTER PLZ <br />SANTA ANA, CA 92701 <br />Q9 1988-2014 ACORD CORPORATION, All rights reserved. <br />ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD <br />