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ONEOCOO-01 JOHCI3
<br />CERTIFICATE OF LIABILITY INSURANCE
<br />OAT/YYYY)
<br />1//20/20/DD2016
<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
<br />CONTACT
<br />NAME: CindiJohnson
<br />Newport Beach, CA - Inland Empire - HUB International Insurance Services
<br />PRONE FAx
<br />(A/p No E.t):(949) 623-3980 L(AIC,Nel: (949) 891.0407
<br />Inc.
<br />4695 MacArthur Court
<br />E-MAIL - - - _--- - _
<br />ADDRESS:
<br />Suite 600
<br />Newport Beach, CA 92660
<br />_. __ INSURER(S)AFFORDING-COVERAGE I NAIC#
<br />_
<br />INSURER A: Philadelphia Indemnity Insurance Company 118058
<br />INSURED
<br />INSURER B 4
<br />OneOC
<br />INSURER C
<br />1901 E. Fourth Street, Suite 100
<br />INSURER D
<br />Santa Ana, CA 92705
<br />-_- --- ---- --
<br />-INSURER E : '
<br />INSURER F:
<br />COVERAGES 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 />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 ADDL SUBRPOLICY EFF POLICY EXP- T
<br />LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MMDD/YYYY LIMITS
<br />q X COMMERCIAL GENERAL LIABILITY
<br />X
<br />EACH OCCURRENCE_
<br />GWTORFNTED
<br />— 1,000,000
<br />_ CLAIMS -MADE occuR X
<br />IPHPK1445599 01/15/2016'.01/15/2017
<br />PREMISES Ea occurrence)_
<br />5 500,000
<br />MED EXP (Any one person)
<br />$ - _ _.. _ 20,000
<br />PERSONAL &_ADV INJURY
<br />$ 1,000,000
<br />35000,000
<br />IT GREGATE LIMIT APPLIES PER
<br />GENERAL AGGREGATE
<br />rGEN
<br />PRO
<br />h POLICY �� JECT LOC
<br />T,$
<br />- PRODUCTS COMP/OP AGO $ 3,000,000
<br />OTHER..
<br />SOCIAL SERV PRO $ 2,000,000
<br />AUTOMOBILE LIABILITY
<br />COMUI ar�NED SINGLE LIMIT 1,000,000
<br />$
<br />A ANY AUTO
<br />IPHPK1445599 101/15/2016101/15/2017
<br />Ili
<br />1 BODILY INJURY (Per person s'$
<br />AOSCHEDULED
<br />AUTOS AUTOS
<br />-
<br />I BODILY INJURY Per accltlenl $
<br />'AUTOSS NON -OWNED
<br />X HIREDNON AUTOS X
<br />11 PROPERTY DAMAGE — $ -
<br />_LPer accidence.
<br />�i,
<br />I $
<br />X UMBRELLA LIAB I X '
<br />�ti; OCCUR
<br />EACH OCCURRENCE5_
<br />A EXCESS LIAB CLAIMS -MADE(
<br />1,
<br />IPHUB528327 01/15/20161
<br />01/15/2017
<br />.4,000,000
<br />I_ AGGREGATE_ IS
<br />$ 4,000,000
<br />DED X RETENTION$ 10,000!
<br />WORKERS COMPENSATION
<br />____
<br />_
<br />PER 0TH
<br />AND EMPLOYERS'LIABILITY Y/N1
<br />STATU TE I ER
<br />EL EACHACCIDENT$
<br />ANY PROPRIETORIPARTNERIEXECUTIVE I
<br />OFFICERIMEMBER EXCLUDED? IJ
<br />N/A
<br />�'I
<br />_..-
<br />((Mandatory in NH
<br />1,
<br />E, L. DISEASE - EA EMPLOYEE ($
<br />If yes, describe under
<br />'..
<br />DESCRIPTION OF OPERATIONSbelow-_�--
<br />JI
<br />E. L. DISEASE - POLICY LIMIT $ _
<br />AT—Directors
<br />q IIDi er ctors & Officers
<br />I,PHSD1112487 Dl/1 $/2076
<br />01/15/2017
<br />Liability Limit 1,000,000
<br />DESC RI PINION OF OPERATIONS /LOCATIONS /VIER IDLES (ACORD 101, Additional Remarks Sched ule, may be attached if more space is required)
<br />RE: Project: Portola Park; 1700 E. Santa Clara Ave., Santa Ana, CA 92705����ff,,�� a
<br />Certificate holder named as Additional Insured as their Interest may appear subject to terms and conditions of a CtO I: attach . n
<br />CERTIFICATE HOLDER CANCELLATION
<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 />—
<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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