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<br />'° W® CERTIFICATE OF LIABILITY INSURANCE °03/739123102017
<br />0017
<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 [San ADDITIONAL INSURED, fhe 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 />PRODUCER
<br />NAME. -
<br />DOCUMENT V07H RESFECT TO V'rHiCH THIS
<br />Momentous Insurance Brokerage Inc
<br />PHONE 818 933-2700 FAX
<br />INC.No E`0; (8 18) 1_ lac, He): (818)
<br />933»2701
<br />6990 Sepulveda Blvd., #550
<br />_ _
<br />AIL
<br />/NSRTYPE DFINSURANCE pDDL SUep POLICY NUMBER - IMJADrVYYnI PGLICYEFF tMMM ay)YL
<br />Van Nuys, CA 41411
<br />ADDRESS;
<br />A X'II COMMERCRI-GENERALLIABILITY
<br />ry,
<br />N -20.r 8-004
<br />INSURER{S)AFFORENNGCOVERAGE
<br />SAMA
<br />PREMISES(Ea oauvancei $
<br />INSURER A; Philadelphia Indemn(ty Insurance Company
<br />18058
<br />...
<br />INSURED
<br />INSURERB;State Compensation Insurance Fund -MAIN
<br />35076
<br />Bioemy Management LLC
<br />INsTI c: Sent! nel Insurance Company
<br />11000
<br />P.O. Bax 12529
<br />INSURER D:
<br />GEML AGGREGATE LIMIT AP We$PER:
<br />Newport Beach, CA 9265E
<br />POLICY ytc'7 LOC
<br />PROOUCTS-GOMPIOPAGG $
<br />IN@VRCa C:
<br />0TH
<br />I't, `,.L- ( 1 t-',..•"'"`�
<br />INSURER FI
<br />A AUTOMOBILE LIABILITY -
<br />rM/FRAfSFC rFRTJMr.ATF An IMRPR•
<br />RFVIsHQN NIIMRFR-
<br />X ANY AUTO PHPK1608B51 03124/2017 03/2412018
<br />THS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
<br />INDICATED. NOTWITHSTAND4NG ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER
<br />DOCUMENT V07H RESFECT TO V'rHiCH THIS
<br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 18 SU BJECT TO ALL THE
<br />TERMS,
<br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
<br />/NSRTYPE DFINSURANCE pDDL SUep POLICY NUMBER - IMJADrVYYnI PGLICYEFF tMMM ay)YL
<br />LIMITS
<br />A X'II COMMERCRI-GENERALLIABILITY
<br />EACH OCCURRENCE $
<br />2,000,000
<br />'DAMACETORENTED
<br />. -. CLAIMS-MADE-� X.; OCCUR - PHPK260$$81 0312412011 0312412018
<br />PREMISES(Ea oauvancei $
<br />100,000
<br />MED EXP (Any, ane pPoor) $
<br />0
<br />,
<br />P MISONAL a ADV INJU RY -$
<br />2,000,000
<br />GEML AGGREGATE LIMIT AP We$PER:
<br />GENERALAGGREGATE S4,000,000
<br />POLICY ytc'7 LOC
<br />PROOUCTS-GOMPIOPAGG $
<br />4,000,000
<br />0TH
<br />A AUTOMOBILE LIABILITY -
<br />COMBINED SINGLE LIMIT s
<br />Ice wcd.N)
<br />1,000,000
<br />X ANY AUTO PHPK1608B51 03124/2017 03/2412018
<br />BODILY INJURY(per peman) $.
<br />AUr�FU Pr�FSONLY - X A{U{�1TQppSUryLNE�O❑
<br />- BpODRY WJUpRY (Pet ACeidemj, S
<br />. X . PUTOD50NLY . AUTOR UNLY
<br />(PRMae�Ri�i,i)AMAi3E $
<br />_- UMBRELLA LIAR �', OCCUR
<br />EACH OCCURRENCE S
<br />EXCESS LIAR'- CLAIMS -MADE
<br />AGGREGATE $
<br />DEP RETENTIONS
<br />S
<br />B AND EMP44YERS NEAT RY
<br />- X 9TATVfE ER O
<br />YIN - 9201107-16 12/23/2016 05/01/2017
<br />1,000,000
<br />ANY PROPRIETORNARTNFORIEXECUTIVE
<br />EXCLU E01 N I A
<br />E.L. EACH ACCIDENT $
<br />GFFICERIMF.MBER
<br />{Mandalay In NH) '- -
<br />El, DISEASE - EA EMPLOYEE 3
<br />11000,000
<br />lives,1=THb0 uwer
<br />1,000,000
<br />'OESCPoP ION OF OPEI?ATI oetaw
<br />E.I.. DISEASE-PpLiCY�.iMiT $
<br />C I Susinoss Owners Poli 723SAARS861 03/1512017 03/15/2018
<br />BPP
<br />50,006
<br />anaonea I( mora spade Is RgVI di
<br />DESCRIPflON OF OPERAmO#S t LOCATIONS t VEniCLES {ACrIRD tot, RdtlHiapai Rema[%e ScAedula Very contributory endorsement
<br />Certificate holder is Insured the Primary and
<br />named as additional per attached endorsements. non
<br />atta%ed,-
<br />City of Santa Ana Parks, Recreation 8. Community
<br />Services Agency
<br />1825 W. Civic Center
<br />Santa Ana, CA 92701
<br />-ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />THE POLICY PROVISIONS.
<br />AUTHORIZED REPRESENTATIVE
<br />AUURO 25 (701 6103) ©1988,2015 ACORD CORPORATION. All rights reserved,
<br />The ACORD name and logo are registered marks of ACORD
<br />
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