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FALCUSA•01 CHOUDHARIAV
<br />elC'C>/T[7 CERTIFICATE OF LIABILITY INSURANCE
<br />("-'� -�
<br />DATE 121'121DDn Yn
<br />1 211 212 01 6
<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 INSURERB), AUTHORIZED
<br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER,
<br />IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy 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 endorsement(s).
<br />PRODUCER
<br />Willis Of Seale Inc.
<br />C/0 26 CantUy lVd
<br />P.O. Box 30581
<br />Nashville, TN 37230.6191
<br />CONTACT Willis Certificate Center
<br />.7876 FAAICX No): 688) 467.2378
<br />Rcwlllis.com
<br />INSURORIBI AFFORDING COVERAGE NgIC N
<br />INSURER A: COVOrYS Specialty Insurance Company
<br />INBUREO
<br />___15686
<br />INSURER B:GreenwichInsurance Company 22322
<br />INSURER C: Steadfast Insurance Company 26387
<br />Care Ambulance Services, Inc.
<br />INSURERO:XL Insurance America Inc. 24664
<br />1517 West Braden Court
<br />Orange, CA 92868
<br />INSURER E:
<br />INSURER F:
<br />X
<br />COVERAGES CERTIFICATE NUMBER! REVISION NIIMRER-
<br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW NAVE BEEN ISSUEDTO THE INSURED NAMEDABOVE FORTHE POLICY PERIOD
<br />INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOROTHER DOCUMENTWITH RESPECTTO WHICHTHIS
<br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECTTO ALL TFIETERMS,
<br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
<br />ILTR
<br />TYPE OF INSURANCE
<br />AD4
<br />WVD DR
<br />POLICY NUMBER
<br />MMIDOIVYPW
<br />MMil"olm
<br />LIMITS
<br />A
<br />X
<br />I COMMERCIAL GENERAL LIABILITY
<br />EACH OCCURRENCE
<br />S 1,000,000
<br />CLAIMS -MADE ® OCCUR
<br />X
<br />5.10013
<br />1010112015
<br />10/01/2016
<br />_ERETO R6FflE��
<br />EPId SES,LEkq._Yenca
<br />5 10p,000
<br />X
<br />Products -Claims Made
<br />MED EXP (Any one person
<br />$ 6,000
<br />PER_SON_AL&ADV INJURY
<br />$ Included
<br />_
<br />GEN'L AGGREGATE LIM IT APPLIES PER:
<br />X POLICY ❑ JECT ❑ LOC
<br />GENERAL AGGREGATE
<br />5 2,000,000
<br />PRODUCTS - COMP/OP AGO
<br />$
<br />$
<br />OTHER:
<br />AUTOMOBILE LIABILITY
<br />COMBINED SINGLE LIMIT
<br />G nt
<br />$ 1,000,000
<br />BODILY INJURY In., person)
<br />S
<br />B
<br />X ANY AUTO
<br />X
<br />RAD5000476
<br />10/0112016
<br />10101/2016
<br />AUTOS SCHEDULED
<br />NON -OWNED
<br />HIREDAUTOS AUTOS
<br />BODILY INJURY (Par accident)
<br />'T
<br />$UT
<br />PROPERTY DAMAGE
<br />(ear accident)_
<br />S —
<br />UMBRELLA LIAR
<br />Xj
<br />OCCUR
<br />EACH OCCURRENCE
<br />$ 15,000,000
<br />AGGREGATE
<br />% 16,000,000
<br />C
<br />X EXCESS LIAR
<br />CAMS -MAGE
<br />X
<br />UMB 6414770.02
<br />10/01/2016
<br />10/01/2016
<br />DED RETENTION$
<br />$
<br />D
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY VIN
<br />ANY PROPRIETOR/PARTNER/EXECUTIVE
<br />OFFIOERIMEMBER EXCLUDE09
<br />(Mandatary In NH)
<br />NIA
<br />RWD3000956
<br />10101/2015
<br />10/01/2016
<br />X PER T -
<br />TATUTE _ ER_
<br />EL. EACH ACCIDENT
<br />S 1,000,000
<br />E, L. DISEASE - EA EMPLOYEE
<br />$ 1,000,000
<br />Ifyyes describe under
<br />1) SdRIPTION OF OPERATIONS below
<br />I
<br />I
<br />I E.L. DISEASE -POLICY LIMIT
<br />3 1,000,000
<br />_
<br />A
<br />Mise Medical Prof.
<br />510013
<br />10101/2015
<br />10/01/2018
<br />See Attached
<br />DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES (ACORD 101, Additional Remarks Schedule, may W reached if more apace Is requital)
<br />THIS VOIDS AND REPLACES PREVIOUSLY ISSUED CERTIFICATE DATED 1112412015
<br />UmbrolialExcess Follows Form. The City of Santa Ana and OCFA, and their respective officers, officials, employees, representative and volunteers are
<br />Included as Additional Insureds per Contract or Agreements with the City of Santa Ana in accordance with the policy provisions of the General Liability,
<br />Automobile Liability, and UmbrolialExcess Liability policies. The Policies evidanced herein are Primary and Non -Contributory to other insurance available to
<br />Additional Insureds, but only in accordance with the policy's provisions.
<br />Excess coverage of $15,000,000 applies as Excess coverage over Commercial General Liability, Products; Medical Professional Liability and Automobile
<br />Liability coverage.
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />/A Pw? r THE EXPIRATION THE THEREOF, NOTICE WILL BE DELIVERED IN
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />i "5
<br />AUTHORIZED REPRESENTATIVE
<br />The City of Santa Ana and OC
<br />FA l�.P[ �'%�I f/
<br />655 E. Memory Lane I / �`'fl ,I (,t,�L,�
<br />Sonata Age - CA 92702 I // 6
<br />©1988.2014 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
<br />
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