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A� CERTIFICATE OF LIABILITY INSURANCE g09129/2015Y)
<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 the
<br />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 ondorsement(s).
<br />PRODUCER CONTACT Sarlah Devereaux-Barrientos, Agent NAME Sarlah De,veraaux-Barrientos
<br />1202 W 1St St 19/G No Est): 714FAX
<br />-541-728Q UIC No 714-384-3892
<br />EMAIL
<br />stateFarm Santa Ana, CA 92703 ADDRESS $,ariah.devereauX tBlbCtatefarm.com
<br />INEURER(S)APPORDINGCOVERAGE ,.. NAICA
<br />INSURER A: State Farm General insurance Company 25151
<br />INSURED Carlos Madrlles INSURER B:
<br />. _._....-..._...
<br />DBA Downtown Stadium Grill INsuRERC.
<br />602 N Flower St, Santa Ana, CA 92703 INSURERD
<br />INSU RERE
<br />"' �l^ts:�s1' 4 i[,r•4./1 INSURER F:
<br />COVERAr FR
<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
<br />DOCUMENT WITH RESPECT TO WHICH THIS
<br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED
<br />HEREIN IS SUBJECT TO ALL THE TERMS.
<br />EXCLUSIONSAND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
<br />ILITI TYPEOFINSURANCE ADDL SUER POGcYEFF--POLICYEXP
<br />INBR D POLICYNUMBER MMIDDNYYY MMIDDIYYYI'
<br />- -'
<br />LIMITS
<br />A GENERAL LIABILITY
<br />G._. Y 92-EDZ9660 I. 09129/2076 09129/2016
<br />EACH OCCURRENCE $ 1,000,000
<br />X COMMERCIAL GENERAL LIABILITY '..
<br />----.
<br />DAMAGE TO RENTED - -
<br />PREMISES (Eaoccprrencej $._ _... 300,000
<br />CLAIMS -MADE _.... OCCUR
<br />..._..._
<br />MEq EXP (Any one person) $ $,000
<br />___._ ..... ...._.
<br />PERSONAL &ADV INJURY ',S 1,000,000
<br />..... ....._ ........
<br />GENERAL AGGREGATE $ 2,000,000
<br />GE_N'L AGGREGATE LIMIT APPLIES PER:
<br />PRODUCTS-COMPIOP AGG $ 2,000,000--
<br />POLICY JE`T LOC
<br />KUsin ass Property S 25000
<br />AUTOMOBILE LIABILITY
<br />OM81NED SINGLELIMIT
<br />❑�, _(Eacadenl)
<br />,.__.. $
<br />ANYAUTO�a
<br />1
<br />BODILY INJURY (Per person) $
<br />ALLOWNED SCHEDULED
<br />-
<br />._: AUTOS AUTOS a
<br />BODILY IN -JURY (Perwrimmn $
<br />..- HIRED AUTOS _ NON-OWNED't�
<br />AUTOS
<br />PAOPERTY DAMAGE
<br />(Per amdmm
<br />UMBRELLA LIAR t
<br />- OCCUR ❑❑'., Q ��! ''`n, ;\�
<br />EACH OCCURRENCE S
<br />EXCESS LIgB
<br />_.ES CLAIMSMADE. ` / /a,yCt
<br />V Q
<br />AGGREGATE _. _. $ _.
<br />DEC RETENTIONS
<br />5
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY �\
<br />WC STATU OTH
<br />TORY LIMITS ER
<br />YIN J
<br />ANY PROPRIETOWPARTNERIEXECUTIVE
<br />OFFICEIMEMBER EXCLUDED' , NIA ❑,. ��+
<br />_ _ -_
<br />'
<br />E.L EACH ACCIDENT S
<br />iMandatory In NIH —.
<br />E.L. DISEASE
<br />If yes, describe under
<br />EA EMPLOYEE $
<br />ESC F 02ERATIO
<br />Er- DISEASE -POLICY LIMIT $
<br />El.,'I.
<br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more spacers required)
<br />Certificate holder, it's officers, agents, and employees are named as Additional Insured in regards to General Liability.
<br />*30 days notice of cancellation for nonpayment.
<br />Additional Insured:
<br />City of Santa Ana, its officers, employees, agents, and
<br />representatives
<br />PO Box 1988 Santa Ana, CA 92702
<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 />Sarlah Devereaux-Barrientos
<br />©1988-2010 ACORD CORPORATION. All rights re:
<br />AUUMU Zo jAUI u/ub) The AGORD name and logo are registered marks of ACORD 1001486 132849.8 01-23-2013
<br />
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