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A� a CERTIFICATE OF LIABILITY INSURANCE
<br />DA17
<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 />CONTACT Stacy Grassfield
<br />NAME
<br />Lake Insurance Agency
<br />PNONE (714)263-3600 aG No: 1]141838-]668
<br />AIL
<br />ADDRESS, stacyWlakeins. corn
<br />653 South B Street, Suite 200
<br />Lic #0747473
<br />INSURERS AFFORDING COVERAGE NAIC II
<br />INSURER A:Phi ladel his Ind. Ins. Co.
<br />Tustin CA 92780
<br />INSURED
<br />INSURERB:State Compensation Insurance 35076
<br />INSURER C:
<br />The Cambodian Family
<br />INSURER D:
<br />1626 E. 4th Street
<br />INSURER E:
<br />1 INSURER F:
<br />Santa Ana CA 92701
<br />COVERAGES CERTIFICATE NUMBER:17-18 PRG 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 />INSR
<br />LTR
<br />TYPE OF INSURANCE
<br />ADDL
<br />L02
<br />UBR
<br />POLICY NUMBER
<br />POLICY EFF
<br />MM/DD/YYYY
<br />POLICY EXP
<br />fMM1DDIYYYYl
<br />LIMITS
<br />X COMMERCIAL GENERAL LIABILITY
<br />EACH OCCURRENCE $ 1,000,000
<br />A
<br />CLAIMS -MADE OCCUR
<br />DAMAGE TOD 100,000
<br />PREMISES Es occccurrence $
<br />MED EXP (Any one person) $ 51000
<br />X
<br />PHPK1602100
<br />3/9/2017
<br />3/9/2D1B
<br />PERSONAL &ADV INJURY $ 11000,000
<br />GEN'L AGGREGATE LIMIT APPLIES PER:
<br />GENERAL AGGREGATE $ 3,000,000
<br />X POLICY DjEO LOC
<br />PRODUCTS - COMP/OP AGG $ 11000,000
<br />Abuse/Molesle6on Agg. $ 1,000,000
<br />OTHER:
<br />AUTOMOBILE
<br />LIABILITY
<br />COMBINED SINGLE LIMIT $
<br />Ea accident
<br />BODILY INJURY (Per Person) $
<br />A
<br />ANY AUTO
<br />ALL OWNEDSCHEDULED
<br />AUTOS 'Y AUTOS
<br />PHPR1602100
<br />3/9/2017
<br />3/9/2018
<br />BODILY INJURY (Per accident) $
<br />X
<br />NON -OWNED
<br />HIRED AUTOS X AUTOS
<br />PROPERTY DAMAGE
<br />Per accident $
<br />Non -owned $ 11000,000
<br />X
<br />I UMBRELLA LIAR
<br />OCCUR
<br />EACH OCCURRENCE $ 11000,000
<br />AGGREGATE $ 11000,000
<br />AEXCESS
<br />LIAB
<br />CLAIMS -MADE
<br />DED X RETENTION$ 10,000
<br />$
<br />PHOB570993
<br />3/9/2017
<br />3/9/2018
<br />WORKERS COMPENSATION
<br />ANDEMPLOYERTLIASILITY YIN
<br />IPER OTH-
<br />STATUTE ER
<br />E.L EACH ACCIDENT $ 11000,000
<br />B
<br />ANY PROPRIETOR/PARTNER/EXECUTIVE
<br />OFFICER/MEMBER EXCLUDED'! �
<br />(Mandatory in NH)
<br />NIA
<br />906498617
<br />6/30/2017
<br />6/30/2018
<br />E.L. DISEASE - EA EMPLOYE $ 11000,000
<br />H Yas, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />E.L. DISEASE -POLICY LIMIT $ 1,000 000
<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 / LOCATIONS / VEHICLES (ACORD 101, Addulonal 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. A
<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 />ACORD 25 (2014/01)
<br />INS025 (2D1ao1)
<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 rights reserved.
<br />The ACORD name and logo are registered marks of ACORD
<br />
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