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o a® CERTIFICATE ®F LIABILITY INSURANCE
<br />DATE(MMIDDI
<br />`�
<br />1..
<br />9/9/201717
<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 poiicy(ies) 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 />CONTACTNAME: Stacy Grassfield
<br />Lake Insurance Agency
<br />PHONN Ex (719)263-3600 AIC No: (714)B38-7568
<br />E-MAIL stac @lakeins.com
<br />REEY
<br />653 South B Street, Suite 200
<br />Lic #0747473
<br />INSURER(S) AFFORDING COVERAGE NAIC#
<br />INSURER A:Philadel hia Ind. Ins. Co.
<br />Tustin CA 92780
<br />INSURED
<br />INSURERB:State Compensation Insurance 35076
<br />The Cambodian Family
<br />INSURER C:
<br />1626 E. 4th Street
<br />INSURER O:
<br />INSURER E:
<br />Santa Ana CA 92701
<br />INSURER F:
<br />COVERAGES CERTIFICATE NUMBER:17-18 PKG BA UMB WC PROF 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 />ILTR
<br />TYPE OF INSURANCE
<br />INSD AD L3
<br />BD
<br />POLICY NUMBER
<br />POuDIYYYY
<br />MOILDCYVYV
<br />LIMITS
<br />A
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />CLAIMS -MADE ❑X OCCUR
<br />EACH OCCURRENCE
<br />-DAMAGE
<br />$ 1,000,000
<br />TO -RENTED
<br />PREMISES Ea occurrence)
<br />100,000
<br />$.___
<br />MED EXP (Anyone person)
<br />$ 5,000
<br />X
<br />PEPK1602100
<br />3/9/2017
<br />3/9/2018
<br />_
<br />PERSONAL &ADV INJURY
<br />$ 1,000,000
<br />AGGREGATE LIMIT APPLIES PER:
<br />POLICY a PRO- ❑
<br />JECT LOC
<br />GENERAL AGGREGATE
<br />$ 3,000,000
<br />GEN'L
<br />X
<br />PRODUCTS - COMPIOPAGG
<br />$ 1,000,000
<br />Abu.aimolestetion Agg.
<br />$ 1,000,000
<br />OTHER
<br />I
<br />AUTOMOBILE
<br />LIABILITY
<br />COMBINED SINGLE LIMIT
<br />L_accitlentl
<br />$
<br />__
<br />BODILY INJURY (Per person)
<br />$
<br />A
<br />ANY
<br />ANY AUTO
<br />ALL
<br />AUTOS OWNED SCHEDULED
<br />PEPK1602100
<br />3/9/2017
<br />3/9/2018
<br />BODILY INJURY (Per accident)
<br />$
<br />X
<br />HIRED AUTOS X NON -OWNED
<br />PROP RTY DAMAGEAUTOS
<br />$
<br />Non -owned
<br />$ 1,000,000
<br />X
<br />UMBRELLA LIAR
<br />OCCUR
<br />EACH OCCURRENCE
<br />$____ 1,000,00_0_
<br />AGGREGATE
<br />1,000 000
<br />A
<br />EXCESS LAB
<br />CLAIMS -MADE
<br />DED X RETENTION$ 10,000
<br />_$
<br />$
<br />PHUB570493
<br />3/9/2017
<br />3/9/2018
<br />B
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS'LIABILITY YIN
<br />ANY PROPRIETORIPARTNER/EXECUTIVE-
<br />OFFICERIMEMBER EXCLUDED? I
<br />(Mandatory in NH)
<br />Dyyes,desTIONunder
<br />DESCRIPTION OF OPERATIONS below
<br />NIA
<br />906498616
<br />6/30/2016
<br />6/30/2017
<br />PER OTH-
<br />STATUTE Eft
<br />_
<br />E.L. EACH ACCIDENT
<br />-_
<br />$
<br />E_L DISEASE - EA EMPLOYE
<br />$
<br />E.L. DISEASE -POLICY LIMIT
<br />$
<br />A
<br />Professional Liability
<br />PHPK1602100
<br />3/9/2017
<br />3/9/2018
<br />1,000,000
<br />Sexual or Physical Abuse
<br />1,000,000
<br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 181, Additional Remarks Schedule, may be attached if more space Is required)
<br />City of Santa Ana, Officers, Employees, Agents, Volunteers and Representatives as Additional Insured,
<br />Primary/Non-contributory, Waiver of Subrogation and 30 Days Notice of Cancellation applies, as required
<br />by written contract with Named Insured.
<br />City of Santa Ana
<br />Officers, Employees, Agents,
<br />Volunteers and Representatives
<br />20 Civic Center Plaza, M-25
<br />Santa Ana, CA 92701
<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 />Lake/STAGRA -
<br />©1988.2014 ACORD CORPORATION. All riahts reserved.
<br />ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
<br />INS025 (OM4m)
<br />
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