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<br />,. CERTIFICATE 41= LIABILITY INSURANCE4/4/201.7
<br />DATE (MMIDDNYYY)
<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
<br />Lake Insurance Agency
<br />653 South B Street, Suite 200
<br />Li,c #0747473
<br />Tustin CA 92780
<br />CONTACT Stacy Grassfield
<br />NAME:
<br />PHONE (714)263-3600 EA (714)936-75fiB
<br />APC
<br />E-MAIL
<br />ADDRESS: stat @lakeins.com
<br />INSURER S' AFFORDING COVERAGE NAIL 9
<br />INSURER A:Phi,ladel,phia 'Ind. ins. Co.
<br />INSURED
<br />`A,'he Cambodian Family
<br />1626 E. 4th Street
<br />Santa Ana CA 92701
<br />INSURERB:State Compensation insurance. 35076
<br />INSURER C:
<br />INSURER D
<br />INSURER E
<br />INSURER F:
<br />COVERAGES CERTIFICATE NUMBER:17-18 PRG BA U'MB 'W'C PROF 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 />ADDL
<br />SUER
<br />POLICY (NUMBER
<br />POLICY EFF
<br />MMIDDIYYYY
<br />POLICY EXP
<br />MMIDDIYYYY)
<br />LIMITS
<br />X COMMERCIAL GENERAL LIABILITY
<br />EACH OCCURRENCE $ 1,000,000 '.
<br />A
<br />CLAIMS -MADE OCCUR
<br />DAMAGE TO RENTED 100,000',
<br />PREMISES Ea occurrence. $
<br />MED EXP (Any one person) $ 5,000
<br />X
<br />PHPK1602100
<br />3/9/2017
<br />3/9/2018
<br />'..... PERSONAL& AOV INJURY $ 1,000,000
<br />GEN°L AGGREGATE LIMIT APPLIES PER:
<br />''. GENERAL AGGREGATE 3,000,000
<br />X POLICY JECT
<br />❑ PRO- [� LOC
<br />PRODUCTS - COMP/OP AGG $ 1 , 000 ,. 000
<br />Abuse/Molestation Agg. $ 1,000,000
<br />OTHER.
<br />AIUTOMOSILE
<br />LIABILITY
<br />COMBINED SINGLE LIMIT $
<br />Ea accident
<br />BODILY INJURY (Per person) $
<br />AANY
<br />AUTO
<br />ALL OWNED SCHEDULED
<br />AUTOS AUTOS
<br />PHPKI602100
<br />3/9/2017
<br />3/9/2018
<br />ODILYINJURY (Per accident) $
<br />X
<br />NON•OWNED
<br />HIRED AUTOS X AUTOS
<br />....
<br />PRO PERTYDAMAGE
<br />Per aacudenl $
<br />Nor -owned $ 1,000,000
<br />X
<br />UMBRELLA LAS
<br />OCCUR
<br />EACH OCCURRENCE $ 1,000,000
<br />AGGREGATE $ 1,000,000
<br />A
<br />(EXCESS LIAR
<br />CLAIMS -MADE
<br />DED X .RETENTION 10,000
<br />$
<br />....PER
<br />PRUB570493
<br />3/9/2.01.7
<br />3/9/2018
<br />B
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY YIN
<br />ANY PROPRIETOR/PARTNERIEXECUTIVEE.L.
<br />CFRCER/MEMBER EXCLUDED? ❑
<br />(Mandatory in NH)
<br />N I A
<br />906498616
<br />6/3..0/2016
<br />6/30/2017
<br />''.... OTH-
<br />STATUTE ER
<br />EACH ACCIDENT $
<br />E.L. DISEASE - EA EMPLOYE $
<br />If yes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />E.L. DISEASE - POLICY LIMIT $
<br />A
<br />Professional. Liability
<br />PHPK1602100
<br />3/9/2017
<br />3/9/2018
<br />1,000,000
<br />Sexual or Physical Abuse
<br />1,000,000
<br />DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES (ACORD 101, Add111ona11 Remarks Schedule„ may be attached If more space is required)
<br />City of Santa Ana, Officers, Employees, Agents, Volunteers and Representatives as Additional insured,
<br />Primary/Non-contributory, Waiver of Subrogation and 30 Days Notice of Cancellation applies, as required
<br />by written contract with Named Insured,
<br />CERTIFICATE HOLDER CANCELLATION
<br />O 1988-20114 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
<br />IN5025I7n14a t
<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 />Officers, Employees, Agents,
<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 />FtaY3 LaIce/STAGRA
<br />O 1988-20114 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
<br />IN5025I7n14a t
<br />
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