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a`o�zo® CERTIFICATE OF LIABILITY INSURANCE
<br />ATE
<br />D6/28/2018 )
<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 />Lake Insurance Agency 1�
<br />CONTACT Stacy Grassfield
<br />NAME: Y
<br />AHoNN E, (714) 263-3600 FAX
<br />No: (]14)838-'1568
<br />653 South B Street, Suite 200
<br />EMAIL atac ®lakeina.com
<br />ADDRESS: l'
<br />LiC #0747473
<br />INSURERS AFFORDING COVERAGE NAIC0
<br />INSURER A:Phi lade l hia Ind. Ina. Co.
<br />Tustin CA 92780
<br />INSURED
<br />INSURER B:Phi lade l hia Insurance Co.
<br />The Cambodian Family '
<br />INSURERC:State Compensation Insurance 35076
<br />INSURER D:
<br />1626 E. 4th Street
<br />INSURER E,
<br />Santa Ana CA 92701
<br />INSURER F:
<br />COVERAGES CERTIFICATE NUMBER:18-19 GL BA WC 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 />OL
<br />I=
<br />UBR
<br />JMILPOLICY
<br />NUMBER
<br />MOLICY�
<br />POLICY EXP
<br />LIMITS
<br />A
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />CLAIMS -MADE � OCCUR
<br />EACH OCCURRENCE $ 11000,000
<br />DAMAGE( NTEDEa occurrence $ 100,000
<br />PREMISESS
<br />MED EXP (Any one person) $ 5,000
<br />X
<br />PHPK1766819
<br />3/9/2018
<br />3/9/2019
<br />PERSONAL B ADV INJURY $ 1,000,000
<br />AGGREGATE LIMIT APPLIES PER:
<br />POLICYJERCT L PO- LOC
<br />GENERAL AGGREGATE $ 3,000,000
<br />GEN'L
<br />X
<br />PRODUCTS -COMPIOPAGG $ 1,000,000
<br />Abuse/Molestation Agg, $ 11 000, 000
<br />OTHER:
<br />AUTOMOBILE
<br />LIABILITY
<br />COMBINED SINGLE LIMIT $
<br />Ea accident)
<br />BODILY INJURY (Per person) $
<br />AX
<br />ANY AUTO
<br />ALL OWNED SCHEDULED
<br />SCHEDULED
<br />X
<br />3/9/2018
<br />3/9/2019
<br />BODILY INJURY (Per accident) $
<br />NON -OWNED
<br />HIRED AUTOS X AUTOS
<br />PROPERTY DAMAGE
<br />Per accident $
<br />Nan -owned $ 1,000,000
<br />X
<br />UMBRELLA LIAB
<br />H
<br />OCCUR
<br />EACH OCCURRENCE $ 11000,000
<br />AGGREGATE $ 1,000,000
<br />B
<br />EXCESS LIAB
<br />CLAIMS -MADE
<br />DED X RETENTION$ 10,000
<br />$
<br />1
<br />IPHUB615191
<br />3/9/2010
<br />3/9/2019
<br />C,
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY YIN
<br />ANY PROPRIETOR/PARTNER/EXECUTIVE F7
<br />OFFICEWMEMBER EXCLUDED?
<br />(Mandatory in NH)
<br />If yes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />NIA
<br />906498618
<br />6/30/2018
<br />6/30/2019
<br />X PER OTH-
<br />STATUTE ER
<br />E.L. EACH ACCIDENT $ 1,000,000
<br />E.L. DISEASE - EA EMPLOYEF $ 1,000,000
<br />E.L. DISEASE -POLICY LIMIT $ 11000,000
<br />A
<br />Professional Liability
<br />PHPK1766819
<br />3/9/2018
<br />3/9/2019
<br />11000,000
<br />A Professional Liability
<br />7
<br />11000,000
<br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedul a, may be attached If more space is requ lred)
<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. s
<br />CERTIFICATE HOLDER CANCELLATION
<br />ACORD 25 (2014/01)
<br />INS025 (201401)
<br />©1988-2014 ACORD CORPORATION. All rights reserved.
<br />The ACORD name and logo are registered marks of ACORD
<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 />Officers, Employees, Agents,
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />Volunteers and Representatives
<br />AUTHORIZED REPRESENTATIVE
<br />20 Civic Center Plaza, M-25
<br />Santa Ana, CA 92701
<br />Bob Lake-C/L/STAGRA t -
<br />ACORD 25 (2014/01)
<br />INS025 (201401)
<br />©1988-2014 ACORD CORPORATION. All rights reserved.
<br />The ACORD name and logo are registered marks of ACORD
<br />
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