|
A� n® CERTIFICATE OF LIABILITY INSURANCE
<br />006/22/2017 )
<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(les) 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 />Denise K Hudson Insurance Agency, Inc
<br />License # 06865301045 W Katella Ave Ste 240
<br />StateFaf�la
<br />® Orange, CA 92867
<br />®®,
<br />CONTACT LORRIE SABAN
<br />NAME:
<br />AHCNNo Ex :714-633-6118 FAX
<br />noDaess: IOrrie@denisekhudson.com
<br />INSURER($) AFFORDING COVERAGE
<br />NAIC ft
<br />INSURER A:State Farm General Insurance Company
<br />25151
<br />INSURED WESTERN AIV INC
<br />INSURER B:State Farm Mutual Automobile Insurance Company
<br />25178
<br />1592 N BATAVIA ST STE 2
<br />INSURER C:
<br />CLAIMS -MADE � OCCUR
<br />ORANGE, CA 92867
<br />INSURER D :
<br />INSURER E
<br />NSURER F:
<br />MED EXP (Any one person) $ 5,000
<br />COVERAGES CERTIFICATE NUMBER: 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 />INSR
<br />LTR
<br />TYPE OF INSURANCE
<br />ADDL
<br />INSR
<br />SUBR
<br />WVD
<br />POLICY NUMBER
<br />POLICY EFF
<br />MMIDDIYYYY
<br />POLICY EXP
<br />MMIDDIYYYY
<br />LIMITS
<br />A
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />Y
<br />92 -EX -5166-6
<br />05/1612017
<br />05/16/2016
<br />EACH OCCURRENCE $ 2,000,000
<br />CLAIMS -MADE � OCCUR
<br />PREMISES Ea occurrence $ 300,000
<br />MED EXP (Any one person) $ 5,000
<br />PERSONAL &ADV INJURY $ 1,000,000
<br />GEN'L AGGREGATE LIMIT APPLIES PER',
<br />GENERAL AGGREGATE $ 4,000,000
<br />POLICY ❑ PRO- ❑ LOC
<br />JECT
<br />PRODUCTS-COMP/OPAGG $ 4,000,000
<br />BUSINESS PROP $ 234,500
<br />OTHER.,
<br />B
<br />AUTOMOBILE
<br />LIABILITY
<br />375 9392 -F17 -75P
<br />06/17/2017
<br />1211712017
<br />COMBINED SINGLE LIMIT $ 1,000,000
<br />Ea accident
<br />BODILY INJURY (Per person) $
<br />ANY AUTO
<br />X
<br />AOX SCHEDULED
<br />AUTOS AUTOS
<br />BODILY INJURY (Per accident) $
<br />HIRED AUTOS )( NON -OWNED
<br />AUTOS
<br />PROPERTY DAMAGE $
<br />Per accident
<br />A
<br />X
<br />UMBRELLAUAB
<br />X
<br />OCCUR
<br />92 -XC -0351-6
<br />12114/2016
<br />12/14/2017
<br />EACH OCCURRENCE $ 5,000,000
<br />AGGREGATE $
<br />EXCESS LIAB
<br />CLAIMS -MADE
<br />DED I I RETENTION$
<br />$
<br />A
<br />WORKERS COMPENSATIONi
<br />AND EMPLOYERS' LIABILITY YIN
<br />ANY PROPRIETORIPARTNERIEXECUTIVE
<br />92 -EK -R799-1
<br />01/01/2017
<br />01/01/2018
<br />PER OTH-
<br />STATUTE ER
<br />E.L. EACH ACCIDENT $ 1,000,000
<br />OFFICER/MEMBER EXCLUDED? ❑NIA
<br />(Mandatory in NH)
<br />E.L. DISEASE - EA EMPLOYE $ 1,000,000
<br />Ues, describe order SCRIPTION OF OPERATIONS below
<br />E.L. DISEASE - POLICY LIMIT $ 1,000,000
<br />DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required)
<br />AUDIO VISUAL SERVICE & INSTALLATION
<br />Business Location #1 6353 Corte Del Abeto, Suite 106, Carlsbad, CA 92011/Business Location #2 1592 N Batavia St., Ste 2, Orange, CA 92867
<br />Certificate Holder, City of Santa Ana, its officers, employees, agents, volunteers & representatives are additional insured
<br />CERTIFICATE HOLDER CANCELLATION
<br />IRl
<br />@ 1988-2014 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD 1001486 132849.9 02-04-2014
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />CITY OF SANTA ANA
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />20 CIVIC CENTER PLAZA
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />SANTA ANA, CA 92701
<br />AUTHORIZED REPRESENTATIVE /I
<br />XXI/
<br />IRl
<br />@ 1988-2014 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD 1001486 132849.9 02-04-2014
<br />
|