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AC °D® CERTIFICATE OF LIABILITY INSURANCE
<br />ggTE (MMIDDIYYYY)
<br />8/31/2016
<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 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 />InterWest Insurance Services
<br />License 40B01094
<br />222 Court Street
<br />NAME: Michelle Goodwin, CIC, CISR, CPSR
<br />PHDNE 831 -635 -2247 F4X 831-638-6801
<br />E -MAIL . mgoodwin @iwins_com
<br />INSURE R($) AFFORDING COVERAGE
<br />Me#
<br />Woodland CA 95695
<br />INSURERA:Liberty Insurance Corporation
<br />42404
<br />$1,000,000
<br />INSURED USHEA -1
<br />INSURER B:Liberty Mutual Fire Ins Co.
<br />23035
<br />U.S. Healthworks Holding Company, Inc.
<br />INSURER c:Safety National Casualty Corp
<br />15105
<br />25124 Springfield Ct., Ste 270
<br />Valencia CA 91355
<br />INSURER D
<br />PERSONAL $ADVINJURY
<br />INSURER E
<br />GEN'L
<br />AGGREGATE LIMIT APPLIES PER:
<br />POLICY E PEA LOC
<br />OTHER'
<br />INSURER F
<br />$2,000,000
<br />COVERAGES CERTIFICATE NUMBER: 810747776 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
<br />LTR
<br />TYPE OF INSURANCE
<br />INSD
<br />WVD
<br />POLICY NUMBER
<br />POLICY EFF
<br />MMfDO
<br />POLICY EXP
<br />MM1DDNYYY
<br />LIMITS
<br />B
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />CLAIMS -MADE � OCCUR
<br />Y
<br />TB2691450294036
<br />9/1/2016
<br />9/1/2017
<br />EACH OCCURRENCE
<br />$1,000,000
<br />DAMAGE TO RENTED
<br />PREMISES Ea occurrence
<br />$1,000,000
<br />MED FRCP (Any one person)
<br />$10,000
<br />PERSONAL $ADVINJURY
<br />$1,000,000
<br />GEN'L
<br />AGGREGATE LIMIT APPLIES PER:
<br />POLICY E PEA LOC
<br />OTHER'
<br />GENERAL AGGREGATE
<br />$2,000,000
<br />PRODUCTS - COMPIOPAGG
<br />$2,000,000
<br />$
<br />B
<br />AUTOMOBILE
<br />LIABILITY
<br />ANYAU70
<br />AUT OWNED SCHEDULED
<br />HIRED AUTOS X NON -OWNED
<br />AUTOS
<br />AS2691450294045
<br />9/1/2016
<br />9/1/2017
<br />COMBINED SINGLE LIMIT
<br />Eaacci ED
<br />$ 1,000,000
<br />X
<br />BODILY INJURY (Per person)
<br />$
<br />BODILY INJURY (Per accident)
<br />$
<br />X
<br />PROPERTY DAMAGE
<br />Per accident
<br />$
<br />$
<br />A
<br />X
<br />UMBRELLA LIAR
<br />EXCESS LIAR
<br />X
<br />OCCUR
<br />CLAIMS -MADE
<br />1
<br />TH7691450294056
<br />9/1/2016
<br />9/1/2017
<br />EACH OCCURRENCE
<br />$25,000,000
<br />AGGREGATE
<br />$25,000,000
<br />DED I X I RETENTION 10,000
<br />$
<br />C
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY YIN
<br />ANY PROPRIETORIPARTNERlEXECUTIVE
<br />OFFICEFJMEMBER EXCLUDED?
<br />(Mandatory in NH)
<br />If yes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />NIA
<br />LDC4042721
<br />9/112016
<br />9/1/2017
<br />PER OTH-
<br />X STATUTE ER
<br />E.L. EACH ACCIDENT
<br />$2,000,000
<br />E.L. DISEASE - EA EMPLOYEE
<br />$2,000,000
<br />E.L. DISEASE - POLICY LIMIT
<br />$2,000,000
<br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Addltlonal Remarks Schedule, may be attached if more space is required)
<br />Re: 1619 East Edinger, Santa Ana, CA 92705 Certificate holder is included as additional insured when required by written contract per the
<br />attached endorsements.
<br />%Imr% 1 Ir141p% I C nvLLJMM L,AIYL rLLAI IVIV IV VaYa IIVLH,G IVI IIVII V[1VIIItNII
<br />City of Santa Ana
<br />20 Civic Center Plaza
<br />Santa Ana CA 92701
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />AUTHORIZED REPRESENTATIVE
<br />bkluVLZ
<br />©1988 -2094 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2014181) The ACORD name and logo are registered marks of ACORD 4 1
<br />
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