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A� " CERTIFICATE OF LIABILITY INSURANCE
<br />r ATE (MMIDD /YYYY)
<br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
<br />6/30/2016
<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(ies) must have ADDITIONAL INSURED provisions or be endorsed.
<br />If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
<br />this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
<br />PRODUCER ICA Insurance Services
<br />130 Vantis, Suite 250
<br />AlISO Viejo, CA 92656
<br />NAME: Betty Tran
<br />PHONE FAX
<br />AAMAILo Ext : 949 297 -5962 A/C No : 949 -297-5960
<br />ADDRESS: betty.tran @ioausa.com
<br />INSURERS AFFORDING COVERAGE NAIC #
<br />7/1/2016 7/1/2017
<br />wsURERA: RLI Insurance Company 13056
<br />www.ioausa.com CA License #OE67768
<br />INSURED
<br />Albert Grover & Associates, Inc.
<br />211 East Imperial Hwy, Suite 208
<br />Fullerton CA 92835
<br />INSURER B: RSUI Indemnity Company 22314
<br />IN suRERC: Continental Casualt Com an 20443
<br />INSURERD:
<br />INSURER E:
<br />INSURER F:
<br />s$ 1X0,000
<br />COVFRAGFS CERTIFICATE NUMBER! gn7nFFt1q RFVISION NIIMRFRr
<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 />INSR
<br />LTR
<br />TYPE OF INSURANCE
<br />ADDL
<br />NS
<br />SUBR
<br />WV
<br />POLICYNUMBER
<br />POLICY EFF POLICY EXP
<br />MMIDD/YYYY MM /DD/YYYY
<br />LIMITS
<br />A
<br />,/ '.. COMMERCIAL GENERAL LIABILITY
<br />✓
<br />✓
<br />PSB0001618
<br />7/1/2016 7/1/2017
<br />EACH OCCURRENCE
<br />$ 1,000,000
<br />CLAIMS -MADE I � OGCUR
<br />Scheduled AI Endt
<br />DAMAGE TO RENTED
<br />PREMISES Ea occurrence
<br />s$ 1X0,000
<br />✓ '.. Primary /Non - Contributory
<br />#
<br />#PPB3130212
<br />MED EXP (Any one person)
<br />$ 10,000
<br />Professional Services
<br />✓ Waiver of Subrogation
<br />PERSONAL &ADV INJURY
<br />_
<br />$ 1,000,000
<br />performed by the Insured
<br />GEN'L AGGREGATE LIMIT APPLIES PER:
<br />GENERAL AGGREGATE_
<br />$ 2,000,000
<br />are Excluded
<br />POLICY ✓❑ PE' ❑✓ LOC
<br />PRODUCTS - COMP /OP AGG
<br />$ 2,000,000
<br />$
<br />OTHER:
<br />A
<br />AUTOMOBILE LIABILITY
<br />I
<br />I PSB0001 618
<br />7/1/2016 7/1/2017
<br />COMBINED SINGLE LIMIT
<br />(Ea accident)
<br />$ 1,000000
<br />ANY AUTO
<br />j
<br />Included in General
<br />BODILY INJURY (Per person)
<br />$
<br />OWNED SCHEDULED
<br />AUTOS ONLY AUTOS
<br />Liability
<br />BODILY INJURY (Per accident)
<br />$
<br />HIRED NON -OWNED
<br />PROPERTY DAMAGE
<br />Per accident
<br />_
<br />$
<br />✓ AUTOS ONLY ✓ AUTOS ONLY
<br />Is
<br />B
<br />UMBRELLA LIAB
<br />�/ OCCUR
<br />NHA240508
<br />7/1/2016 ( 7/1/2017
<br />EACH OCCURRENCE
<br />$ 2,000,000
<br />✓ EXCESS LIAR
<br />CLAIMS -MADE
<br />Excludes Professional
<br />I Liability; Follow Form
<br />AGGREGATE
<br />_
<br />$ 2,000,060
<br />DED RETENTION $
<br />$
<br />1
<br />1
<br />A
<br />WORKERS COMPENSATION
<br />/
<br />IPSW0001494
<br />7/1/2016 7/1/2017
<br />,/ IPTER EORH
<br />AND EMPLOYERS' LIABILITY YIN
<br />Waiver of Subrogation
<br />E.L. EACH ACCIDENT
<br />is 1,000,000
<br />ANYPROPRIETOR /PARTNERIEXECUTIVE
<br />I
<br />OFFI CER/M EMBER EXCLUDED? Y
<br />NIA
<br />i Endt #WC0403060484
<br />E.L. DISEASE - EA EMPLOYEE
<br />$ 1,000,000
<br />(Mandatory in NH)
<br />If yes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />E.L. DISEASE - POLICY LIMIT
<br />_
<br />$ 1,000,000
<br />C
<br />Professional Liability
<br />IMCH288354455
<br />7/1/2016 7/1/2017
<br />$2,000,000 Each Claim
<br />Claims -Made
<br />I
<br />$4,000,000 Aggregate
<br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
<br />Certificate Holder is an Additional Insured with respect to General Liability (GL) but only when required by written contract with the Insured prior
<br />to an occurrence as per Endorsement noted above. GL includes Separation of Insureds and Contractual Liability per limitations in the BusinessOwners'
<br />Coverage form. A Workers' Compensation Waiver of Subrogation as noted above is included for the person or organization named in the Schedule
<br />that are parties to a contract requiring this y orsement, rovl e that contract IS executed ore t e S ove r Y subjec_ t to all ll pol-ic,_ y terms
<br />conditions, limitations and exclusion. 30 Da Notice Cancellation/10 Days for Non-Payment in accorda p ce with cprovisions
<br />W
<br />RLVPEVVED BY: EUI\H L. HER1" DIA 0"'C' r "t y � �.....
<br />GtK I It-ILA I t t1ULUtK GANL tLLA I IUN
<br />Speed Survey 2015
<br />City of Santa Ana SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />Y THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />its officers and employees ACCORDANCE WITH THE POLICY PROVISIONS.
<br />PO Box 1988
<br />20 Civic Center Plaza, M -93
<br />Santa Ana CA 92702 AUTHORIZED REPRESENTATIVE
<br />(AVC) Alicia K. Igram
<br />@ 1988 -2015 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
<br />30705613 1 7 /16 -P GS /EXCE•, /W(. /... ..,. -,i,.: '.ir 11, .iu , C, U1¢i ) Al,, (PD'I) 1 e - - crf 3
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