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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 />