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A� p® CERTIFICATE OF LIABILITY INSURANCE
<br />DATE)
<br />6/30/2016
<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 />Hays Companies
<br />4200 Concours, Suite #350
<br />Ontario CA 91764
<br />CONTACT Nilda Garcia
<br />NAME:
<br />PHONEO EXIT et
<br />(909)243-8111 F_ N
<br />AIL
<br />ADDRESS: ngarcia@hays companies. com
<br />INSURERS AFFORDING COVERAGE
<br />NAIC p
<br />INSURERA:Great American Ins. Co. of NY
<br />22136
<br />INSURED
<br />Boys & Girls Clubs of Central Orange Coast
<br />250 N. Golden Circle Drive, #104
<br />Santa Ana, CA 92705
<br />INSURERB:Great American Insurance Co.
<br />16691
<br />INSURERC:Great American Alliance
<br />26832
<br />INSURERD: Insurance Company of the West
<br />27847
<br />INSURER E:
<br />EACH OCCURRENCE $ 1,000,000
<br />NSURERF:
<br />CI-AIMS-MADE141OCCUR
<br />COVERAGES CERTIFICATE NUMBER:CL166722142 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 />IN SR
<br />R
<br />TYPE OF INSURANCE
<br />ADDL
<br />SUER
<br />POLICY NUMBER
<br />POLICYEFF
<br />MMLODI EXP
<br />LIMITS
<br />X
<br />COMMERCIAL GENERAL LI ABILITY
<br />EACH OCCURRENCE $ 1,000,000
<br />A
<br />CI-AIMS-MADE141OCCUR
<br />DAMAGE TO RENTED 300,000
<br />PRE ISE c urrance $
<br />X
<br />MED EXP (Any one person) $ 10,000
<br />Professional Lliabiltv
<br />X
<br />PAC4614128
<br />2/11/2016
<br />2/11/2017
<br />X
<br />Sexual Misconduct
<br />PERSONAL B ADV INJURY $ 1,000,000
<br />GEN'L AGGREGATE LIMIT APPLIES PER:
<br />GENERAL AGGREGATE $ 3,000,000
<br />X POLICY PEO E LOC
<br />PRODUCTS - COMP/OP AGG $ 3,000,000
<br />SEXUAL ABUSE COV $ 1,000,000
<br />OTHER:
<br />AUTOMOBILE
<br />LIABILITY
<br />COMBINED SINGLE LIMIT $ 1,000,000
<br />Ea accident
<br />BODILY INJURY(Perperson) $
<br />IS
<br />X
<br />ANY AUTO
<br />ALL OWNED F7 SCHEDULED
<br />AUTOS AUTOS
<br />CAP4614129
<br />2/11/2016
<br />2/11/2017
<br />BODILY INJURY(Per accident) $
<br />NON -OWNED
<br />HIRED AUTOS AUTOS
<br />PROPERTY DAMAGE $
<br />Pereccid.rd
<br />Medical paynneris $ 5,000
<br />X
<br />UMBRELLALIAS
<br />OCCUR
<br />EACH OCCURRENCE $ 5,000,000
<br />AGGREGATE $ 51000,000
<br />L,
<br />EXCESS LIAB
<br />CLAIMS -MADE
<br />DED X RETENTION 10,000
<br />$
<br />06164614130
<br />2/11/2016
<br />2/11/2017
<br />WORKERS COMPENSATIONPER
<br />AND EMPLOYERS' LIABILITY VIN
<br />OTH -
<br />X STATUTE ER
<br />E.L. EACH ACCIDENT $ 1,000,000
<br />ANY PROPRIETORIEXCLUDRIEXECUTIVE
<br />D
<br />(MandatoryOFFICERIMIn ER EXCLUDED? ❑
<br />(Mandatory In NH)
<br />If yes, describe under
<br />N/A
<br />WVE 5033839
<br />6/1/2016
<br />6/1/2017
<br />E.L. DISEASE - EA EMPLOYEF $ 1,000 000
<br />DESCRIPTION OF OPERATIONS below
<br />E.L. DISEASE -POLICY LIMIT $ 1,000,000
<br />A
<br />PM4614128
<br />2/11/2016
<br />2/11/2017
<br />Blanket REP: $610,000
<br />Property R/C: Spcl Form
<br />Deductible: $1,000
<br />DESCRIPTION OF OPERATIONS 1 LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
<br />City of Santa Ana, Community Development Agency is Additional Insured;
<br />�/�`�
<br />V �l_/ -
<br />CERTIFICATE HOLDER CANCELLATION
<br />ACORD 25 (2014101)
<br />INS025 r9nt4011
<br />©1988-2014 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, Community
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />Development Agency
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />20 Civic Center Plaza, M-25
<br />AUTHORIZED REPRESENTATIVE
<br />Santa Ana, CA 92701
<br />N Mershon/NGARCI
<br />ACORD 25 (2014101)
<br />INS025 r9nt4011
<br />©1988-2014 ACORD CORPORATION. All rights reserved.
<br />The ACORD name and logo are registered marks of ACORD
<br />
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