COMMUNITY HEALTH INITIATIVE OF ORANGE COUNTY-2017

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CERTIFICATE OF LIABILITY INSURANCE ATE F;/2(MNVDDfYYYY) 1/2018 THIS CERTIFICATEIS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER PAYCHEX INSURANCE AGENCY INC/PAC 250881 P: F: (888) 443-6112 PO BOX 33015 SAN ANTONIO TX 78265 CONTACT NAME: (A/CNo,Ext): (a ,Nc>: (888) 443-6112 E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC# INSURERA: Hartford Ins Co of the Midwest 37418 INSURED COMMUNITY HEALTH INITIATIVE OF ORANGE COUNTY 1505 E 17TH ST STE 121 SANTA ANA CA 92705 INSURER B INSURER C: INSURER D INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICYNU,IIBER POLICYEFF tIMIDD POLICYE.VP 11 LARTS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE ❑ OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICYEJ PRO LOC JECT PRODUCTS - COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE HIRED NON -OWNED AUTOS ONLY AUTOS ONLY (Per accident) $ 5 UMBRELLA LIAB d OCCUR EACH OCCURRENCE s AGGREGATE $ EXCESS LIAB CLAIMS -MADE DE RETENTION $ $ WORKERS COSIPENSA TIO,V ANDEMPLOiE'RYLIABILITY X PER OTH- STATUTE ER E.L. EACH ACCIDENT $1, 000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N A OFFICER/MEMBER EXCLUDED? (Mandatory in NH) ❑ N/A 76 WEG PK2991 11/01/2017 11/01/2018 E.L. DISEASE -EA EMPLOYEE $11 000 000 If yes, describe under DESCRIPTION OF OPERATIONS below s 1 0 00,000 E.L. DISEASE - POLICY LIMIT I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) Those usual to the Insured's Operations. A,,,,o�i CERTIFICATE HOLDER CANCELLATION © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. CITY OF SANTA ANA 20 CIVIC CENTER PLZ # M-17 AUTHORIZED REPRESENTATIVE SANTA ANA, CA 92701 © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD