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CERTIFICATE OF LIABILITY INSURANCE I DATE (MM;°°"cYY' 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(les) 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 PRODUCER INSURED R.T. Clown, Inc. 461 Altura Way Manhattan Beach CA 90266-2369 COVERAGES CERTIFICATE NUMBER: 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 RESPECTTO 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. INS# _ —_.. .. AODLj§Usk ".... _. _. _—.______ __..____. —POLICY all POLICY EXP R+_ TYPE OFiNSURANCE POLICY NUMBER MMIDDlYYYY MMlOD Y Y LIMITS A p/ COMMERCIAL GENERAL LIABILITY r/ NN573g53 8/14/2015 0/14/2016 EACH OCCURRENCE $ 1,000,000 CIAIMS MADE ✓ OCCUR I PREM SESOEs ctnma )� S 100,000 BUPD Deductible $5 _ i MED EXP one § 5,000 PERSONAL&ADV INJURY _. IS 1,000,000 L & INJURY - LIES PER' GCN't AGeRLGATa LIMIT APPLIES GENERAL AGGREGATE is 2,000,000 _ ✓ POUCVJE r_ LOC, PRODUCTS-COMPIOP AGG S included — _s — _ 11 OTHER: y AUTOMOnILE LIABILITY COMBINED SINGLE LIMIT is Ca rcldenl_ JJ ANY AUTO i BODILY INJURY (Per parson) I S ,ALL OWNED - SCHEDULED 6001LV INJURY (Per acc den1-11S AUTOS AUTOS 1NON-OWNED HIRED AUTOS _ AUTOS '.,. \'/, 1elP �• ,/p PROPERIVDAMAGC N (Pm acmdent_ I _ \�'+� 1 UMBRELLA UAL OCCUR Q! _EACH OCCURRENCE IS EXCESS LIAR CLAIMS -MADE, AGGREGATE l5 eJ�',ry _ DED I RETENTIONS S '.WORKERS COMPENSATION "I ;� ,�, ,, PER OTH- STA'NTE AND EMPLOYERS' LIABILITY YIN .-.. ... _ .ANY PROPRIETORtPARTNERIEXECU'rIVE"-?' OFFICER/MEMBER EXCLUDED? �: NIA, l' F L EACH ACCIDENT S -----"- — —'- I(Mandatory inNIBY � CL DISEASE - EA EMPLOYE S (If yes. daee ia.,, de[ DESCRIPTION OF OPERATIONS helow E.L. DISEASE -POLICY LIMIT($ I II , DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schetlale, may be attached If mom.face 1. required) Certificate holder named additional insured as respects general & form# 0500. primary liability but only if required by signed written contract with named insured prior included in form# L805 0500. Policy to terms, conditions and to an occurrence per L805 wording subject all policy exclusions. CFRTIFICATr 1401 TRIPP CANCEI.I_ATION The City Ot Banta Ana Y 20 CIVIC Center Plaza SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, Santa Ana CA 92701 AUTHORIZED REPRESENTATIVE Ton D"Asara O 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD Si1%3161 1 .5-111 OI, w/A1 I 'Jan Rang 17/29/2011 1;36:58 CM MDT( I Page 1 of 2