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MERCY -2 OP ID: SD
<br />CERTIFICATE OF LIABILITY INSURANCE
<br />DATE (MMItltlIYYYV)
<br />0 511 9/2 0 1 5
<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 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
<br />Dufour Insurance Services, LLC
<br />5611 Littler Drive
<br />Huntington Beach, CA 92649
<br />Stephanie Dufour
<br />NOME CT Stephanie Dufour
<br />(AInNNo.E,n:714. 369.299$ alc No: 714•$40.6387
<br />noDRless: Ste hanle dufourinsurance.com
<br />INSURERS AFPDRDING COVERAGE
<br />NAIC#
<br />INSURERA i Great American Insurance Com a
<br />Twiv 1-k -L. 4aL"1 )
<br />INSURED Mercy Hausa Living Centers Inc
<br />P,O. Box 1905
<br />Santa Ana, CA 92702
<br />INSURER 8: Great American Insurance Com a
<br />T Property l
<br />INSURER C:raveers rc P y Casual h'
<br />INSURER D
<br />EACH OCCURRENCE
<br />- — — — — —
<br />INSURER E
<br />A
<br />INSURER F:
<br />X
<br />COVERAGES CERTIFICATE NUMBER: RFVIRION NIHLARPP-
<br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
<br />INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPEC`r TO WHICH THIS
<br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
<br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
<br />NSR
<br />TYPE OF INSURANCE
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />20 Civic Center Plaza Box 1988
<br />POLICY NUMBER
<br />(Q m) E
<br />P
<br />LIMITS
<br />Twiv 1-k -L. 4aL"1 )
<br />GENERAL LIABILITY
<br />-k-
<br />EACH OCCURRENCE
<br />- — — — — —
<br />$ 1,000,006
<br />A
<br />COMMERCIAL GENERAL LIABILITY
<br />CLAIMS -MADE ® OCCUR
<br />X
<br />PAC426.08.82
<br />05/02/2015
<br />05/0212016
<br />RE1ES Eaoccurrence
<br />$ 706x000
<br />MEO E %P (Any ono person
<br />$ 10,000
<br />PERSONAL &ADV INJURY
<br />$ 1,000,000
<br />GENERAL AGGREGATE
<br />$ 2,000,000
<br />GEN'L AGGREGATE
<br />LIMIT APPLIES PER:
<br />PRODUCTS - COMP /OPAGG
<br />$ 2,000,006
<br />X POLICY
<br />PRO- LOC
<br />IECT
<br />Dad.- $0
<br />$
<br />LIABILITY
<br />MBINED SINGLE LIMIT
<br />(E[�accden {h
<br />1,000,000
<br />BODILY INJURY (Per person)
<br />$
<br />A
<br />ANY AUTO
<br />X
<br />PAC426 -08 -82
<br />05/0212015
<br />0510212016
<br />hAU,TOMOBILE
<br />ALL AUTOS NED X SCHEDULED
<br />AUTO
<br />HIRED AUTO$ X NON -OWNED
<br />AUTOS
<br />BODILY INJURY(Per sooident)
<br />$
<br />PROP DAMAGE
<br />PER CCIDENT
<br />Ti A`.
<br />Dad- $500
<br />$
<br />X
<br />UMBRELLA LIAB
<br />X
<br />OCCUR
<br />EACH OCCURRENCE
<br />$ 4,000,000
<br />B
<br />EXCESS LIAB
<br />CLAIMS-MADE
<br />X
<br />UMB 4260883
<br />05/02/2015
<br />05/02/2016
<br />AGGREGATE
<br />$ 4,000,000
<br />DED I X I RETENTION $ 10000
<br />mm
<br />$
<br />C
<br />ANDEM PWORKERS
<br />ANY PROPRIETOR /PARTNER /EXECUTIVE Y/N
<br />OPPICER/MEMBEP CXCLUOEW F—]
<br />(Mandatory in NH)
<br />If gqes,desaibeunder
<br />OGSCRIP'rION OF OPERATIONS below
<br />NIA
<br />UB4216T17715
<br />02108/2015
<br />02108/2016
<br />X TORY LATH- �TRH-
<br />ELEACHACCIDENT
<br />$ 1,000,600
<br />E.L. DISEASE- EA EMPLOYEE
<br />$ 1,000,000
<br />E.L. DISCASE - POLICY LIMIT
<br />$ 1,000,000
<br />A
<br />Professional Llabl
<br />X
<br />PAC426.08.82
<br />05/0212015
<br />05/0212016
<br />Per Occ 1,000,000
<br />A
<br />Abuse Liability
<br />X
<br />PAC426.08.82
<br />05/0212015
<br />05/02/2016
<br />Aggregate 1,000,060
<br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required)
<br />Re: CDBG, ESG, and HPRP grants. City of Santa Ana, its officers, employees,
<br />agents, volunteers and representatives are named additional insureds with
<br />respect to the operations of the named insured & this policy is primary per
<br />the attached endorsement. Workes compensation coverage excluded, evidence
<br />only, 19 days notice of cancellation for non - payment of premium.
<br />CERTIFICATE HOLDER CANCELLATION
<br />ACORD 25 (2610/05)
<br />O 19882010 ACORD CORPORATION. All rights reserved.
<br />The ACORD name and logo are registered marks of ACORD
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />City of Santa Ana
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />Frank Hernandez
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />20 Civic Center Plaza Box 1988
<br />AUTHORIZED REPRESaNTARVE
<br />Santa Ana, CA 92702
<br />Twiv 1-k -L. 4aL"1 )
<br />ACORD 25 (2610/05)
<br />O 19882010 ACORD CORPORATION. All rights reserved.
<br />The ACORD name and logo are registered marks of ACORD
<br />
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