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<br />CERTIFICATEQF LIABILITY INSURANCE
<br />TE
<br />DAT/12/2g16Y)
<br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN I$ SUBJECT TO ALL THE TERMS,
<br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
<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 pollcy(los) 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 ondorsoment(s).
<br />PRODUCER
<br />NAME:C JoAnn Meyer
<br />Lake Insurance Agency
<br />PH Ne 714)263-3fitip �f'FAX
<br />/V xNw.fxkJ;...t -t_MG Noh ('114)B3S-)SBS
<br />653 South B Street, Suite 200
<br />- -----
<br />AtlARRS$.joanntIlakeins.com
<br />�._.................... _...--`------ ---------------
<br />LiC 110747473
<br />---- -'----
<br />INSURER(S)AEEORD114GCOVERAGE NAlCA
<br />Tustin CA 92760 _
<br />IMSUf+eR A:Philadelohia Ind, Ins. Co.
<br />INSURED
<br />INSURERB:State CoMpdpsatlon Insuranc!9..,
<br />35076
<br />The Cambodian Family
<br />INSURER C:
<br />1626 E. 4th Street
<br />_
<br />INSURER E:
<br />9 100,400
<br />INSURER E:
<br />X
<br />Santa Ana CA 92701
<br />COVERAGES CERTIFICATE NUMBER:16-17 PRG WC TIME REVISION NUMBER:
<br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED 1'O THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
<br />INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
<br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN I$ SUBJECT TO ALL THE TERMS,
<br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
<br />INSR LTRTYPE OEIN$URANCHbC $TleaRRn "n POLICY NUMBER ROCKY IFF PO ICYe P LIMITS
<br />X COMMERCIAL GENERAL LIABILITY
<br />20 Civic Center Plaza, M-25
<br />Santa Ana, CA 92701
<br />I2nb take/JOANNN r
<br />EACH OCCURRENCE
<br />$ 11000,000
<br />TSAFAAGkf
<br />A
<br />CLAIMS -MADE LR OCCUR
<br />ShGMlsesES flE. Ea oocurrg/ygQj-„_
<br />9 100,400
<br />X
<br />PIIPKI461345
<br />3/9/2016
<br />3/9/2017
<br />MEDEXP(Anyoneparson)
<br />$ 51000
<br />PERSONAL&ADVINJURY
<br />$ 11000,000
<br />GEN'L AGGREGATE. LIMIT APPLIES PER:
<br />GENERAL AGGREGATE
<br />$ 3,000,000
<br />X POLICY�jR�I' J LOC
<br />PRODUCTS-GOMP/OP AGG
<br />$ 1,000,000
<br />Abuse/Moloslation Am.
<br />$ 1,000,000
<br />OTHER:
<br />AUTOMOBILE
<br />LIABILITY
<br />0 N LE LI I'
<br />$
<br />LL
<br />Z=
<br />ED 01LYINJItRY(Por porson)
<br />$
<br />A
<br />ANY AUTO
<br />ALL OWNED SCHEDULED
<br />AUTOS AUTOS
<br />P8Pr1461345
<br />3/9/2016
<br />3/9/2017
<br />BODILYINJURV Reraceldent
<br />( I
<br />$
<br />X
<br />'X
<br />NON�OWNED-------
<br />HIRED AUTOS '�` Autos
<br />_-
<br />PH PEFIYDAMAGE
<br />IpAr cfdenll -—
<br />$� ---'
<br />_------
<br />Non -owned
<br />$ 11000,000
<br />X
<br />-
<br />UMBRELLALIAB_
<br />OCCUR
<br />EACH OCCURRENC-
<br />$ 1 00b,L 000
<br />A
<br />EXCESS LIAB
<br />CLAIMWADE
<br />AGGREGATE,
<br />$ St 000000
<br />DED X I RETENTION 10 000
<br />.,.
<br />Pral3532093
<br />3/9/2016
<br />3/9/2017
<br />WORKERS COMPENSATIONPER
<br />X OTH-
<br />AND EMPLOYERTLIABILDY YIN
<br />STATUTE SR_.
<br />E.L.EACH ACCIDENT __
<br />1 000 000
<br />$ _,�.�__t_
<br />ANY PROPRIETOWPARTNEWEXECUTIVE
<br />NIA
<br />B
<br />OFFICERIMEhIBER EXCLUDED'?
<br />'.In NH)
<br />906498615
<br />6/30/2015
<br />E_, DISEASE - EA EMPLOYE
<br />$ 000,000
<br />(Mandatory
<br />6/30/2016
<br />9 mYr. describe under
<br />DESCRIPTIONOFOPERATIONSbolew
<br />—
<br />E,L.DISEASE-POUrYUMIT
<br />-----_-1s
<br />$ 1,000,000
<br />A
<br />Professional Liability
<br />PUYX1461345
<br />3/9/2016
<br />3/9/2017
<br />1000,000
<br />Sexual or Physical Abuse
<br />1,000100)
<br />DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schadula, may be attached if more space la required)
<br />City of Santa Ana, Officers, Employees, Agents, Volunteers and Representatives as Additional Insured,
<br />Primary applies under General Liability per policy form as required by written contract with Named
<br />Insured.
<br />Endorsement to follow from carrier, ,
<br />CERTIFICATE HOLDER CAN rFi.I ATION
<br />CG 1988.2014 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
<br />INS025 onia 111
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />City of Santa Aria
<br />Officers, Employees, Agents,
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />Volunteers and Representatives
<br />AUTHORIZED REPRESENTATIVE
<br />20 Civic Center Plaza, M-25
<br />Santa Ana, CA 92701
<br />I2nb take/JOANNN r
<br />CG 1988.2014 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
<br />INS025 onia 111
<br />
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