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Client#: 756615 <br />THOMHOUS <br />ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE(IAM)OD)YYYY) <br />01/0712016 <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 ACONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORfZED <br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER, <br />IMPORTANT: Ifthe corllflcate holdar Is an"ADDITIONAL INSURED, the poliDy(les) must be endorsed, If SUBROGATION IS WAIVED, sub)eotto <br />the terms anti conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the <br />certificate holder ht Ileo of suoh mrtlorsemenl(s). <br />PRODUCER <br />HUB Int'I Insurance Serv. Inc. <br />License ter Dr. <br />6701 Center Dr. West #1500 <br />ACT <br />Torry Decker <br />o E.1 714.922.4229 Arc No: <br />noDREas: Cal.CPU@htfbinternational.com <br />GENERALLiABiLITY <br />X COMMERCIAL GENERAL LIABILITY <br />CLAIMS -MADE aOCCUR <br />Los Angeles, CA 90046 <br />mericaINSURGAIn)Assur nceCo. 44 <br />msuREan: Great American Assurance Co. 28344 <br />INSURED Thomas House Temporary Shelter <br />PO Box 2737 <br />INSURER s; State Compe1183tlon Ins. Fund 36076 <br />INSURER c: <br />INSURER D: <br />Garden Grove, CA 92842 <br />INSURER E: <br />NSURERP; <br />GENERAI.AGOREGATE $2000,000_ <br />CUVERAUES CERTIFICATE NUMBER: REVISIONNUMBER: <br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN ISSUED TOTHE INSURED NAMEDABOVE FOR THE POLICYPERIOD <br />INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR 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 />L R <br />TYPE OF INSURANCE <br />DDL <br />INR <br />UB <br />POLICY NUMBER <br />PDLpp EF <br />MMIDD <br />P IC P <br />AIhV00 <br />LIMITS <br />A <br />GENERALLiABiLITY <br />X COMMERCIAL GENERAL LIABILITY <br />CLAIMS -MADE aOCCUR <br />PAC0594539 <br />0/03/2015 <br />10103/201E <br />EACH $1,000,000 <br />�OCCURRENCE _ <br />X115 IENTEbs 100 <br />MEDEXP(Araywaperson) $500000 <br />PERSONAL &ACV INJURY $1,000,000 <br />GENERAI.AGOREGATE $2000,000_ <br />GEN7.AOORWATEMMITAPPLIESPER: <br />POLICY <br />PRC LDC_ <br />PRODUCTS .COMPIOPAGO $2000000 <br />$ <br />A <br />AUTOAIORILROASILBY <br />X <br />ANY AUTO <br />AUTOS NED SCHEDULED <br />HIREDAUTOS X NONOWNCD <br />AUTOS <br />PAC0594539 <br />101091201510/03/201 <br />Epa¢MUbSINGLELAI 1000000 <br />BODILY INJURY (Per Parson) $ <br />BODILY INJURY (Per acddenU $ <br />PROPERTY W—MNGE $ <br />Faracatlant <br />UAIBRSIAA LIAR <br />EXCESS LIAR I <br />OCCUR <br />I CLAIMS -MADE <br />EACH OCCURRENCE $ <br />AGGREGATE $ <br />DEO I I RETEMION5 <br />_ <br />$ <br />B <br />WORKERS COMPENSATION <br />AND EMPLOYERS' UASIUTY <br />ANYPppOppIETOR/PAARRTNNERn��EXECUTIVEYIN <br />OFFICE NKEREREXCIUDED7 � <br />thfandamry In Hit <br />ITyyos daxdlra undo' <br />DESCRIPTION OF OPERATIONS balms <br />NIA <br />488156615 <br />_ <br />10101/2015101011201 <br />WO <br />X STATU DTH. <br />E.L.EACHACCIDENT OOO.00O <br />__$1 <br />E.L. DISEASE -EA EMPLOYEE Ll000000 <br />E.L. DISEASE -POLICY LIMIT $1000000 <br />DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (Attach ACORD 101, Addittonai Ramarka Schoduta, If more apace is required) <br />City of Santa Ann, its officers, Officials, agents, and employees are additional insured in regard to <br />General Liability per attached form CG822412101. <br />V_v <br />City of Santa Ann <br />Attn: Terri Eggars <br />20 Civic Center Plaza <br />Santa Ann, CA 92701 <br />.SHOULD ANY OF THE ABOVE DESCRIBED POLICIES DE CANCELLED BEFORE <br />THE EXPIRATION DATA THEREOF, NOTICE WILL BE DELIVERED IN <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />AUTHORIZEO REPRESENTATNF. <br />@1988-2010 ACORD <br />ACORU 2$ (2010/05) 1 of 1 The ACORD mmne and logo are registered marks of ACORD <br />#537027171M3702713 TD41 <br />reserved <br />