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acoR& CERTIFICATE OF LIABILITY INSURANCE
<br />k.----
<br />DATE(MMIDDfYYYY)
<br />1
<br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
<br />10/19/2018
<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(ies) must have ADDITIONAL INSURED provisions or be endorsed.
<br />If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
<br />this certificate does not confer rights to the certificate holder in (leu of such endorsement(s).
<br />PRODUCER
<br />CONTACT
<br />NAME:
<br />StateFarm ROY JEFFERSON, AGENT
<br />PHONE714-283-5338 FAX No : 714-283-5941
<br />A0 ® 115 S CHAPARRAL CT, SUITE 250
<br />E ogle roy@royjefferson.net
<br />INSURER(S) AFFORDING COVERAGE NAIC#
<br />ANAHEIM, CA 92808
<br />INSURERA: State Farm General Insurance Company 25151
<br />AMA E TO HEN
<br />PREMISES Ea occurrence)
<br />INSURED
<br />INSURER B: State Fann Mutual Automobile Insurance Company 25178
<br />-AIMTD LLC
<br />INSURER C :
<br />751 WEIR CANYON ROAD, SUITE 157-158
<br />_
<br />INSURER D: _
<br />__
<br />ANAHEIM, CA 92808
<br />INSURER E:
<br />INSURER F:
<br />COVERAGES CERTIFICATE NtIMRFR- RFVLSInLJ 61IIMRI=110•
<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 />LTH
<br />TYPE OF INSURANCElNqn
<br />ADDL
<br />SUER
<br />Wyo
<br />POLICY NUMBER
<br />POLICY EFF
<br />M DDFYYYYI
<br />POLICYEXP
<br />(MMIDD/YYYYI
<br />LIMITS
<br />SANTA ANA, CA 92702
<br />COMMERCIAL GENERAL LIABILITY
<br />CLAIMS -MADE M OCCUR
<br />EACH OCCURRENCE
<br />S 2,000,000
<br />AMA E TO HEN
<br />PREMISES Ea occurrence)
<br />S 2,000,000
<br />MED EXP (Any one person)
<br />$ 5,000
<br />PERSONAL e, ADV INJURY
<br />$ 2,000,000
<br />Y
<br />Y
<br />92 -CX -M 179-0
<br />02/26/2018
<br />02/26/2019
<br />GEN'L AGGREGATE LIMIT APPLIES PER:
<br />GENERAL AGGREGATE
<br />$ 4,000,000
<br />POLICY [:1J"ECOT- [7] LOC
<br />PRODUCTS - COMP/OP AGG
<br />$ 4,000,000
<br />$
<br />OTHER:
<br />AUTOMOBILE
<br />LIABILITY
<br />Y
<br />Y
<br />435 8589-D25-75
<br />10/19/2018
<br />10/25/2019
<br />COMBINED SINGLE LIMIT
<br />Ea accident1__
<br />$
<br />BODILV INJURY (Per person)
<br />_�
<br />$ 1,000,000
<br />ANY AUTO
<br />OWNED SCHEDULED
<br />AUTOS ONLY AUTOS
<br />515 6448 -CDB -75
<br />10/19/2012
<br />09108/2019
<br />BODILY INJURY (Peraccident)
<br />s 1,000,000
<br />HIRED NON -OWNED
<br />AUTOS ONLY AUTOS ONLY
<br />PROPERTY DAMAGE
<br />Per ecc dent
<br />§ 1,000,000
<br />S
<br />UMBRELLA LIAR
<br />OCCUR
<br />EACH OCCURRENCE
<br />$
<br />AGGREGATE
<br />EXCESS UAB
<br />CLAIMS -MADE
<br />DED I I RETENTIONS
<br />$ T
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITYYIN
<br />ANY PROPRIETOR/PARTNEWEXECUTIVE
<br />OFFICER/MEMBER EXCLUDED? ❑Y
<br />(Mandatory In NMI
<br />NIA
<br />92 -EK -T968-4
<br />02/28/2018
<br />02/28/2019
<br />I PER OTH-
<br />STATUTE ER
<br />E.L. EACH ACCIDENT
<br />S 1,000,000
<br />E.L. DISEASE - EA EMPLOYEE
<br />$ 1.000-000
<br />If yes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />E.L. DISEASE - POLICY LIMIT
<br />$ 1.000,000
<br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached It mom space Is required)
<br />30 DAY NOTICE OF CANCELLATION, EXCEPT FOR 10 DAYS FOR NON-PAYMENT OF PREMIUM WILL BE PROVIDED,
<br />REVIEWED BY: EUNICE HEREDIA (PG I OF )
<br />CERTIFICATE HOLDER CANCELLATION
<br />© AO15 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2016103) The ACORD name and logo are registered marks f ACORD
<br />1001466 132849.12 03-16-2016
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />ADDITIONAL INSURED:
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />CITY OF SANTA ANA DEPARTMENT OF PUBLIC WORKS
<br />AUTHORIZEDTAT]��,
<br />20 CIVIC CENTER PLAZA
<br />SANTA ANA, CA 92702
<br />© AO15 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2016103) The ACORD name and logo are registered marks f ACORD
<br />1001466 132849.12 03-16-2016
<br />
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