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>RIYI`14. DATE(MM/DD/YYYY)...._.,.....,
<br />CERTIFICATE OF LIABILITY INSURANCE 04/26/2017
<br />- ...._... _..._ _ _ ... .. - - __W........,_,.. _.. _......__........._ ..............._.._..........._ .
<br />THIS CERTIFICATE IS ISSU EO AS A MATTER 01=114FORMATION ONLY AND CONFERS NO RIGIfTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOTAFF€RMATIVELY OR NEGATIVELY
<br />AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, THIS CERTIFICATE OF INSURANCE DOES NO•rCONSTITUTEACONTRACT iIETWEENTHE ISSUING IN5URER(S),
<br />AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
<br />M.,-. ,,, ,...._,.w_.........._...., ................ ....__...__...._._........,._..._......._....,............_...._..,.,.,.._-._•_....._......,-.__...._.._...,_.,_.._._.._.,..., _..._......._.. _.. - ...
<br />IMPORTANT: Jf the cer tlRcate holder Is an ADDITIONAL INSURED, the policy(tea) must have ADDITIONAL INSURED proY€dons or be endorsed. If SUBROGATION IS WAIVED, subject to the lerrrls and
<br />conditions of the policy, Certain pgRcies may, require an endorsement. A statement an this cerClIcate does not confer rights to the cert€R4ate holder In lieu of wh endarsament(s).
<br />PRODUCER CONTACT
<br />NAME: Wendy Munoz
<br />_._--.._......___.._......_........ ................. ... ........... .... ...... .... _.
<br />Wend....
<br />Y MunGz (97G104A) PHONE FAX
<br />2441 N Tustin Ave Ste E (A/C,NO, EXT): 714-5504100 (A/C,NO):714•-550-7170
<br />E MAIL
<br />Santa Ana GA 92705-1681 ADDRESS: wniunoz@farmersagent.com - ..... -- -------.....,__._..._........,.
<br />INSUFMR(5)AFFORDING COVERAGE NAIC N
<br />.... _.......... .............. ........ —.._._.. . ..... _......_.._. ...... - _ .,.... _... _.,...-- -—.—..._..-----.._—.._._....
<br />INSURED INSURERA: TfUCkInsurance Exchange 21709
<br />N5UR 1ERB. Farmers Insurance Exchange 21652
<br />ELIZALDE, GUILLERMO .. ._.. _.._.
<br />DOA: SUPER ANTOJITOS EXPRESS 1NSURERC: Mild Century Insurance Company _ 21087
<br />1702 N BRISTOL ST STE D INSURER D:
<br />SANTAANA CA 92708 INSURERS:
<br />1N5URERP:
<br />COVERAGES CERTIFICATE NUMBER: REVISION NUMBER;
<br />THIS €S TO CERTIFY THATTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAME ABOVE FOR THE POLICY PERIOD INDICATED. NOTWIT HSTAN DING ANY
<br />REQUIREMENT, TCRM OR CON DITION OF ANY CONTRACT OR OTI 1ER DOCUMENT WITH RESPECT TO W141CH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAfN, THE INSURANCE AFFORDED BY THE
<br />POLICIES DI'SCRIEED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONOITfONS OF SUCH POLICIES. LIMITS SHOWN MAY 14AVE BEEN REDUCED BY PAID C€AIMS.
<br />_. _._... ..._,_ ......... .. ... ........
<br />1NSR ! 'TYPE ADDTL SLIER NUMBER POLECYEFP POLICYEXP LIMITS
<br />LTR INSO WV0 (MM/DD/YYYY) (MM/DD/YYYY)
<br />—..—..___....._. _ ........_ _ _...._......._. _ _ _ _._.._....._...........
<br />COMMERCIAL GENERALLIABILIYY -••_.---_._, EACH OCCURRENCE $ 100a000
<br />....,
<br />-., CLAIMS-MADEI ! OCCUR DAMAGETORENTED $
<br />PREMISES (Ea OcCurrence) 260OOQ
<br />MEDEXP(Anyonepersan) ;$ 5000
<br />A Y Y 605416467 11/0112015 11l0112017 PERSONAL &ADV INJURY $ 1,000,000
<br />....._.
<br />GEN'L AGGREGATE LIM17APPLIES PER: GENERALAGGRFGATE $
<br />.., is 2,000,000
<br />POLICY PROJECT LOC PRODUCTS-COMP/OPAGG 3 2,000,000
<br />OTHER; $
<br />AUTOMOEILELIADtLFTY CQM9INEOSINGLFUMI7 $
<br />{Ea aeddent)
<br />ANYAUTO 60DILY INJURY (Per person) $
<br />OWNED AUTOS - SCHEDULED BODILY INJURY (Poe accldent) S
<br />ONLY AUTOS
<br />HIREDAUTOS NON -OWNED �'' PROPERTY DAMAGE $
<br />ONLY ; AUTOSONLY � (Per accident)
<br />UMBRELLALIAB OCCUR OCCURRENCE s
<br />EXCIESSLIAB CJAIMS-MADE AGGREGATE f-i) � ATE S
<br />r` »� �i
<br />DE0 RETENTION 0J $
<br />........... _.
<br />WORKERS COMPENSATION
<br />\ Y' PER
<br />ANYOPROPRIETOR/PARTNITY (`- - STATUTE OTHER $
<br />vV _
<br />..
<br />ER/ Y/N N/A
<br />E.L. EACH ACCIDCNT $
<br />EXECUTIVE DED?(Mandat (Mandatory In
<br />E.LDISEASE•CAENIPLOYEE $
<br />EXCLUDE07(MandotorylnNH} T
<br />If yes, dew1be under DESCRIPT101V OF
<br />OPiERATIONSbelgw E.LCISCASE-POLICYLlMIT $
<br />DESCRIPTION OF OPERATIONSAOCATION5/ VEHICLES (ACORD i 01. Addltiona) Rem arks Schedule, may be attached If more space is required)
<br />1702 N BRISTOL ST, SANTA ANA, CA 92706
<br />CERTIFICATE HOLDER CANCELLATION
<br />.._.._,._.__._.W.._...._.._..�,N�CI`P`bFSANTAANA-....-.__.....__.__,____�._._..._..__..._..___..... ..._ .. _....
<br />5HOULDANY OFTHEAROVE OESCRMED POLICIES BE CANCELLED BEFORE THE EXPIRATION
<br />20 CIVIC CENTER PLAZA DATE THEREOF, NOTIC E WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS,
<br />_....._.—....._..._..._..........__..._, ....... ,.,.-
<br />AQ"f rM 6%J1ESENTATIVE
<br />_._....._ ..._-SANTA.ANA ...... ..... CA ..92701
<br />ACORD 25 (2016/03) OO 1988.2015 ACORD CORPORATION. All Rights Reserved
<br />31-t 7S9 1 1.1 S The ACORD name and logo are registered marks Of ACORD
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