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ONE0000-01 JOHCI3
<br />,4coR0" CERTIFICATE OF LIABILITY INSURANCE F
<br />DATE (MN OD/YYYY)
<br />1 1/20/2016
<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(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 endorsement(s).
<br />PRODUCER License # 0757776 CONTACT
<br />NAME, Cindi Johnson
<br />Newport Beach, CA- Inland Empire- HUB International Insurance Services PHONE--- __-- FAx _-- --- --
<br />Inc. ('VC
<br />,No, E.0 (949) 623-3980 __-1IJVC,Ng;_ (949) 891-0407
<br />4695 MacArthur Court EMAIL - -- _- -- -----
<br />Suite 600 ADDRESS__
<br />Newport Beach, CA 92660 _ _ INSUREB(S) AFFORDING COVERAGE _ NAIC #
<br />INSUHERA Philadelphia Indemnity Insurance Company 18058
<br />INSURED _..
<br />INSURER B
<br />OneOC
<br />1901 E. Fourth Street, Suite 100
<br />Santa Ana, CA 92705
<br />INSURER C :
<br />INSURER D
<br />INSURER E:
<br />COVERAGES CERTIFICATE NUMBER- RFVIRInN NIIMRFR-
<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 RESPECTTO WHICH THIS
<br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECTTOALL THETERMS,
<br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE
<br />BEEN REDUCED BY PAID CLAIMS.
<br />(NSR - - iADOL SUER
<br />LTR TYPE OFINSUflANCE .INSD WVD POLICY NUMBER
<br />POLICY EFF POLICY EXP
<br />MWDD/YYYYI flMM1DD/YYYY1 LIMITS
<br />A
<br />X COMMERCIAL GENERAL LIABILITY
<br />EACH OCCURRENCE
<br />$ 1,000,000
<br />CLAIMS L
<br />X
<br />PHPK1445599
<br />01/15/2016
<br />01/15/2017
<br />-DAMAGETORENTEpX—IoccuR
<br />500,000
<br />-MADE
<br />PREMISES(Ea occurrence)_
<br />$
<br />MED EXP (Any one person)
<br />$ 20,000
<br />-PERSONAL &ADV INJURY
<br />$ 1,000,000
<br />GEN'L AGGREGATE LIMIT APPL_I ES PER :
<br />AGGREGATE
<br />I$ 3,000,000
<br />POLICY jECOT LOC
<br />I
<br />—GENERAL
<br />PRODUCTS - COMPIOPAGG
<br />$ 3,000,000
<br />OTHER:
<br />ISOMBAE SERV PRO
<br />is 2,000,000
<br />--
<br />AUTOMOBILE
<br />-- --
<br />LIABILITY
<br />.
<br />L (Ea accitlenl
<br />$ 1,000,000
<br />A
<br />SAW AUTO
<br />PHPK1445599
<br />01/15/2016
<br />01/15/2017
<br />BODILY INJURY (Per person)
<br />__
<br />$
<br />ALL OWNED SCHEDULED
<br />AUTOS AUTOS
<br />(
<br />BODILY INJURY Per accitlenl
<br />( )
<br />$
<br />X-
<br />I— _
<br />X NON -OWNED
<br />FARED AUTOS AUTOS
<br />PROPERTYDAMAGE
<br />LPeraccidenJ_
<br />_ _ __
<br />_ -
<br />$
<br />$. -_
<br />X
<br />UMBRELLA LIAR X ---
<br />OCCUR
<br />�—
<br />—
<br />EACH OCCURRENCE
<br />$ 4,000,000
<br />A
<br />EXCESS LIAB _ 1 CLAIMS-MADEiPHUB528327
<br />j
<br />01/15/2016
<br />01/15/2017
<br />AGGREGATE
<br />_
<br />DEXI RETENTION$ 10,000
<br />D
<br />_
<br />j
<br />I_ _�
<br />4,000,000_
<br />WORKERS COMPENSATION
<br />I PER 0TH-
<br />ANDEMPLOYERS'LIABILITV Y/N
<br />STATUTE ER
<br />ANY PROPRIETOR/PARTNERIEXECUTIVE —
<br />E. L. EACH ACCIDENT
<br />$
<br />OFFICER/MEMBER EXCLUDEDP ��
<br />(MandatoryinNH)
<br />N/A
<br />- -- --
<br />EL DISEASE
<br />--
<br />If ye s, describe under
<br />- EA EMPLOYEE
<br />-- ----- -
<br />$
<br />-
<br />DESCRIPTIONOFOPERATIONS below
<br />E. L. DISEASE -POLICY LIMIT
<br />$
<br />A
<br />(Directors & Officers
<br />PHSD1112487
<br />01115/2016101/15/2
<br />_
<br />Liability Limit 1,000,000
<br />I
<br />j
<br />DESCRIPTION OF OPERATIONS/ LOCATIONS/ VEHICLES (ACORD 101, Additional Remarks Schedule, may be aaached if more space is required) y`ya• _—
<br />�r
<br />RE: Project: Portola Park; 1700 E. Santa Clara Ave., Santa Ana, CA 92705
<br />V
<br />__�`rr,,�I
<br />Certificate holder named as Additional Insured as their Interest may appear subject to terms and conditions of_egrgCgplbrt tach tl, y,
<br />lJ
<br />CERTIFICATE HOLDER
<br />CANCELLATION PIX
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />KaBOOMI, Inc.
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />4301 Connecticut Ave. NW, Suite ML -1
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />Washington, DC 20008
<br />AUTHORIZED REPRESENTATIVE
<br />© 1988.2014 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
<br />
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