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HomeMy WebLinkAboutDR. SCOTT WELDY, DBA SERRANO ANIMAL AND BIRD HOSPITALƒ \ 0 c ƒ ■ / 0 £ ¥ CD 5 m J /. 7 � � Z g c » m /S 7 % o 77 00 c z 2 0 S 0 0 ■ > 0 () 0 m X � 3: 0 O m (A z 7 � 2 o Q r -> > O VA 0 � § o 2 3 j / \ A-2017-191-01 INSURANCE NOT ON FILE WORK MAY NOT PROCEED MAYOR Miguel A. Pulido CLERK OF COUNCIL, MAYOR PRO TEM DATE: AUG 2 9 2019 Juan Milegas COUNCILMEMBERS Cecilia Iglesias David Penaloza Vicente Sarmiento Jose Solorio 0 S t1 ✓te (�ntJti� CITY OF SANTA ANA PARKS, RECREATION AND COMMUNITY SERVICES AGENCY 20 Civic Center Plaza a P.O. Box 1988 Santa Ana, California 92702 www.santa-ana.orc July 23, 2019 Dr. Scott Weldy, D.V.M. Serrano Animal and Bird Hospital 21771 Lake Forest Drive, Suite 111 Lake Forest, California 92630 Re: First Extension to Agreement No. A-2017-191. Dear Dr. Weldy: CITY MANAGER Kdstine Ridge CITY ATTORNEY Sonla R. Cervalho CLERK OF THE COUNCIL Daisy Gomez Pursuant to Section 3 ("Term") of Agreement No. A-2017-191 dated August 15, 2017, entered into by Serrano Animal and Bird Hospital and the City of Santa Ana, the City hereby exercises its first one (1) year optional extension. The Agreement is hereby extended for a one (1) year period, from September 1, 2019 through August 31, 2020. The insurance certificates are required to be extended and/or renewed to cover this extension. All other terms and conditions of the Agreement as amended remain unchanged and in full force and effect. Sincerely, p r !"� C�' Lrsa Rudloff Executive Director, Parks, Recreation and Community Services Agency CITY OF SANTA ANA Knstr���1�� City Manager [Signatures continue on the next page] ATTEST Daisy Gomez j Clerk of the Council SANTA ANA CITY COUNCIL Miguel A. Pulido Juan Villages Vicente Sermlento David Penaloza Jose Saone vacant cedlla Iglesias Mayor Mayor Pro Tern, Ward 5 Ward l Ward 2 Ward ] Ward s were 6 moulido@sanla.am ore willeeasesanla-ana.ao ysermieolo9sanla-anaera doeneloaaasanle-ans.oro 'solonoRsonlo-ana.oro dNeslas®aanla-sna.aa APPROVED AS TO FORM Sonia R. Carvalho City Attorney Laura A. Rossini, Senior Assistant City Attorney SANTAANA CITY COUNCIL Miguel A. Pulitlo Juan Milegas Meame, sarmlento Davltl Penaloza Jose Solorio vacant Cecilia Iglesias Mayor Mayor Pro Tem. Ward 5 WERIt Ward Ward Ward Wow nroullco8senle-ana.oro IyiVemasAsanle-ene ora wulumientoiMssma-ana.oro SoenelozaRssma-ane ora Isolarlo0sanla-ana.wo dalubligauatil l _—IMIRIP SERRANI-01 DTHOMAS 11*. 914/2 � 7" CERTIFICATE OF LIABILITY INSURANCE DATE D/YYYY) `� r4rzo19 THIS CERTIFICATE IS 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. r— 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 C NTACT Dian Thomas Veterinary Insurance Services Company PHONE No, Ext : arc No :(918 921-2266 1400 River Park Drive, #180 Sacramento, CA 95815 IA I dthomas@vise-ine.com INS RE AFFORDING COVERAGE AIC # INSURERA.- Allianz Global/ Fireman's Fund INSURED INSURER B:Preferred Employers Ins 10900 Serrano Animal & Bird Hospital, Inc. INSURER C Scott H. Weldy, DVM 21771 Lake Forest Drive #111 INSURER D ; Lake Forest, CA 92630 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 POLICY NUMBER POLICY EFF POLICY EXPLTR LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE OCCUR �( AZC80928980 7/1/2019 7/1/2020 DAMAGE TO RISES (EaENTED 100,000 IRECn =VD /An — nc. % It 10,000 LAGGREGATELIMITAPPLIESPER: GENERAL AGGREGATE $ 2,000,000 POLICY JELQT LOC PRODUCTS - COMP/OP AGG $ 2,000,000 A AUTOMOBILE LIABILITY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS SSWN AUTOS ONLY X AUOTOS ONLY �AZC80928980 7/1/2019 7/1/2020 COMBINED SINGLE LIMIT $ 1,000,000 BODILY INJURY Perperson) $ IxANY BODILY INNJURY Per accident Parlent AMAC3E 4�BRELLA LIAB ESS LIAB CLAIMS -MADE EACH OCCURRENCE HOCCUR E $ RETENTION $ B WORKERS COMPENSATION ANDEMPLOYERS'LIABILITY ApFFICERIMEMBER EXCLUDED ECUTIVE Y� (Mandatory In NH) If Yes, describe under DESCRIPTION OF OPERATIONS below NIA TN164036-3 - 7/1/2019 7/1/2020 X PER TE 07H- STATU ER EL EACH ACCIDENT 1,000,000 $ E.L. DISEASE - EA EMPLOYE $ 1,000,000 E L DISEASE - POLICY LIMIT $ 1,000,600 DESCRIPTION OF DPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) '30 Day's Notice of Cancellation / 10-Days NOC for non-payment. Certificate holder is named as additional insured Per ABC MultiCover AB9189 0807. City of Santa Ana, its officers, agents and employees are included as addtional insureds. REWMED & APPROVED BEHOLDER "r "`' CANCELLATION 7 2019 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Santa Ana THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ty ACCORDANCE WITH THE POLICY PROVISIONS. Risk Management Divlslo A THA M. LAMBERT 20 Civic Center Plaza, 4th Fum Santa Ana, CA 92702 AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD t-aqu I UI L a r(21Nst Century insurance Named Insured and Mailing Address SCOTT WELDY 22671 REVERE RD EL TORO, CA 92630-6000 E-mail: BIGBIRODOGOAOL.COM Vehicle(s) and Driver(el Veh Yew Mokeffilodel 1 61 OTHE VOLVO544 0 - 2 10 CADI CTS PERFORMANCE COSD 3 67 CHEV CAMARO Veh Rated Driver 4 SCOTT WELDY 5 ROBERT WELDY PERSONAL AUTO POLICY DECLARATION 1Vehicle 10 Number A61289410 1G6DJ5EV2A0142094 1243771-159395 J1.1yZanamsad TIcN 45 0 13 0 AMEND - POLICY CHANGE EFFECTIVE 07/24/19 Account: 21ST CENTURY INSURANCE Customer Service Center. 21st CENTURY INSURANCE 21ST CENTURY PLAZA P.O. BOX 15510 WILMINGTON, DE 19850-5510 Policy No: 8377 29 50 Policy Period: From 04130/19 To: 10130/19 12:01 AM Standard Time Ise Vehicle Discounts/Comments Xlp Mileage 07 NICD ADDITIONAL VEH 92630 1.000 P MCD ADDITIONALVEH 92630 9 999 P MCD ADDITION Chargeable Accidents i 92630 1 Driver Discounts GDDISD5 GDDISD5 GUVEKAGE IS PROVIDED WHERE Coverage A PREMIUM AND A LIMIT OF LIABILITY ARE SHOWN FOR THE COVERAGE _ Limit of Liability - Premium Veh 1 Veh 2 Veh 3 A. Hndil� 1%ry Liability $100, 000 each person Includes 0. 8 per vehicle fraud fee $300000 each accident $ 98.00 5 203.00 $ 30.00 B. Piro arty Damage Liability ^i o0 000 each accident $ 27.0_0 S 159.00 V 27. 00 C. Medical Payments $5 000 each 9.00�^ 58.00 $ 9.00 Uninsured Motorist ..person $100,000 each person D. Bodily lniuy $3o0 000 each accident $ 21.00 $ 106.00 $ 21.00 DAMAGE TO YOUR VEHICLE Veh 1 Veh 2 Veh 3 Actual Cash Value Less Deductible Dad. Dad. Dad. • Comprehensive _ ACV_ $500 J $ 2.00 $ 4:3.00 -No Cove F. Collision T $10o $!iUU t y 14.00 $ 376.00Coyy- Uninsured Motorist D1. Prooft 11-am e _ DErD WAIVE I DED WAIVE 1 $3500 MAX $ 2..00 $ 5.00 $` 2.00 Zi ssi Century --- G. Roadside Assistance $75 each disablement Included Included Included Rental Per day $ 2 S Fl. Reimbursement_ max 1 $750 $ o.0i1 19.00 $ 0.00 .i. Additional Equipment _ Inoluded $1 , 000 $1 , 000 The first $1000 is aulcmallcally Additional Included wilh roverappe E or F. Additional cpveraNc a Is optional_ _ Total ; :t, o0a ,1, 000 ± U . 00 $ 0.00 $ 0.00 Total Premium Per Vehicle $ 173. 00 $ 967 .00 $ 89.00 If the installment bill plan is used, a service charge may apply. Total Premium Endomement(sylAgreement(s) AppllcaUkc TCU-1 (01119) TCU511CA (05/18) TCU631CA (02/12) AU CWF9 1011 Loss Payee (LP), Additional Insured (AI) Drivers Not Rated Veh 5 LP NU VISION CU THE POLLOWING FEE(S) MAY APPLY: 07l24/19 LATE: $&.80 PAYMENT RETURNED (NSF): $10.00 �• . CANCEL; $50.00 INSTALLMENT BILL PLAN SERVICE CHAROE:$4.00 Awlimulmi Cvn rM y -q f-d) WHEN ATTACHED TO THE PERSONAL AUTO POLICY. THESE DECLARATIONS COMPLETE THE POLICY AND REPRESENT 1 HE CURRENT STATUS OF YOUR COVERAGES AND LIMITS OF LIABILITY. Visit 21st.com to make policy changes, pay your premium, and more. Register online todayl For Customer Care rail 800-241-1188. TCU41CA (12114) 21st C tury Insurance Company, P.O. Box 15510, Wilmington, DE 19886-5292 1-M rage t ul z O ((21Nst Century insurance - Named Insured and Mailing Address SCOTT WELDY 22671 REVERE RD EL TORO, CA 92630-5000 E-mail: BIGBIRDDOG®AOL.COM Vehlale(s) and DAver(s) Veh ell - 'MatwliVlodel :: -- 4 98 TOYT RAV4 ar - 5 18 FORD F150 RAPTOR PK vdr Rifted driver PERSONAL AUTO POLICY DECLARATION AMEND - POLICY CHANGE EFFECTIVE 07/24/19 Account: 21 ST CENTURY INSURANCE Customer Service Center: 21st CENTURY INSURANCE 21ST CENTURY PLAZA P.O. BOX 15510 WILMINGTON, DE 19850-5510 Policy No: 8377 29 50 Policy Period: From 04130119 To: 10/30/19 12:01 AM Standard Time Vehlcle ID Number llae Vehicle Dlaco "WC-ommerrts: zip.,- I Mileage o JT3HP10VOW7096930 W MGM 92630 7,201 1 FTFW 1 RG3JFA96316 P MCD4ATD 92630 9.999 D WHERE A PRC-MI[1M yearsTlakets Chergeable Acoidents Driver Discounts Llcvnsvdne nF I IARII ITV ARF CHr1WKl FnR TWF r.nVr-QA - Coverage; __. Lhrllt of Llnbllity Premium Veh4 Vah 5 A. Badi1 Injury t €ability includes 0. 8 per fraud fee _-- _ __- B. Property Damage Liabitity _ Medical Payments $100, 000 each person Saoo, 000 each accident c � 9s.00 S 149.00 _ sloo 000 . _ _e ch_accident _ _. $S 000 _ Wch perawn $,_ 93.00 $ 22.00 122.00 S s3. 00 Uninsured Motorist D. Badl_Injury _ DAMAGE TO YOUR VEHICLE Actual Cash Value Less Deductible $100, 000 each person .5300, 000 each accident Veh 4 Vet+ 6 S 45.00 $ 1-1.00 _$ 84.00 �! $ '10.00 Dad. Ded. E. Comprehensive $100 $500 F. Collision Uninsured Property Damage $100 $500 L)E:!l wAxvir DEL) WATVC $75 each disablement $25 $25 ' $150 $750 $ 79.00 $ 307.00 - I $ 2.00_ included $ 5.00 Included - _ 21st Century G. Roadside Assistance_ Rental -- Per day H. Reimbursement_ _ I max J. Additional Equipment The first $1000 is automatically Included with coverage E or F. Additional coverage Is optional, If the installment bill plan is used, a service $ 19.00 $ 19.00 Included Additional Total Total0.00 $1-, 000 $1, 000 $1.1000 $1, 000 S 0.00 Total Premium Per Vehicle 354.00 $ 808.00 Total Premium $ 2,401.00 charge may apply. Endorsement(s)/Agreement(s) Applicable: Drivers Not Rated 07124/19 THE FOLLOWING FEES) MAY APPLY: LATE: $5.00 PAYMENT RETURNED (NSF): $10.00 . CANCEL: $50.00 INSTALLMENT BILL PLAN SERVICE CHARGE,."00 �uAhOifmr! Cwrvnny gntuoeeminllvo {wlxuu m�pdrrnlj WHEN ATTACHED TO THE PERSONAL AUTO POLICY, THESE DECLARATIONS COMPLETE THE POLICY AND REPRESENT THE CURRENT STATUS OF YOUR COVERAGES AND LIMITS OF LIABILITY. Visit 21st.com to make policy changes, pay your premium, and more. Register online today! For Customer Care call 800-241-1188. TCU41CA (12114) 21s1 Cenlury Insurance Company, P.O. Box 15510, Wilmington, DE 10886-5292 A- q_q-r Lambert, Samantha From: Cuevas, Silvia Sent: Tuesday, September 17, 2019 11:40 AM To: Lambert, Samantha Subject: RE: Request for COI Review: Dr. Scott Weldy dba Serrano Animal and Bird Hospital Hi, yes I confirmed with them and they don't own vehicles. They listed the vehicles that would be used and VIN Ws on the insur ce. Thank you Silvia From: Lambert, Samantha <SLambert@santa-ana.org> Sent: Friday, September 13, 2019 8:31 AM To: Cuevas, Silvia <SCuevas@santa-ana.org> Subject: FW: Request for COI Review: Dr. Scott Weldy dba Serrano Animal and Bird Hospital HI Silvia, I see the automobile liability does not include Owned, did you confirm with the insured the company does not own any vehicles? I see they provided their private auto insurance information but I did not want to presume. Samantha M. Lambert I Risk Management Supervisor Human Resources 120 Civic Center Plaza I Santa Ana, CA 92701 714-647-6959 1 slam bert@santa-ana.ore - 2020 -- 2 2„ SANTA ANA COUNTS f http://www.santa-ana.org/ This e-mail (and attachments, if any) may be subject to the California Public Records Act and as such, may, therefore, be subject to public disclosure unless otherwise exempt under the Act. From: Cuevas, Silvia Sent: Thursday, September 05, 2019 10:08 AM To: RMD <RMD@santa-ana.org> Subject: Request for COI Review: Dr. Scott Weldy dba Serrano Animal and Bird Hospital R °guest for COI Review: Department: Parks, Recreation and Community Services Agency POLICY NUMBER 8 H4 AZC 80928980 AMERICAN BUSINESS COVERAGE POLICY Named Insured SERRANO ANIMAL & BIRD HOSPITAL,WELD GENERAL DECLARATIONS Continued FORMS ATTACHED AT INCEPTION GENERAL PROVISIONS AB0009A 01-87 COMMON POLICY CONDITIONS (AB 00 09A 01 87) IL0270 09-12 CALIFORNIA CHANGES - CANCELLATION AND NONRENEWAL (IL 02 70 09 12) 143003 11-85 DIVIDEND PROVISIONS (143003 11-85) 145917CA 06-04 SILICA PARTICLES EXCLUSION - CALIFORNIA (145917CA 06 04) 145927 01-15 DISCLOSURE OF PREMIUM AND ESTIMATED PREMIUM FOR CERTIFIED ACTS OF TERRORISM COVERAGE (PURSUANT TO TERRORISM RISK INSURANCE ACT) (145927 01 15) 145983 10-13 CIVIL UNION AMENDATORY ENDORSEMENT (145983 10 13) 145985 06-14 ECONOMIC OR TRADE SANCTIONS COMPLIANCE (145985 06 14) PROPERTY/LIABILITY AB0404A 01-87 HIRED AUTO AND NON -OWNED LIABILITY (AB 04 04A 01 87) AB1203 11-94 LOSS PAYABLE PROVISION (AB 12 03 11 94) AB9000 12-93 REV 2 PROPERTY/LIABILITY POLICY (AB 90 00 12 93S) AB9017 06-09 MECHANICAL, ELECTRICAL AND PRESSURE EQUIPMENT COVERAGE ENDORSEMENT (AB 90 17 06 09) AB9051 03-99 UMBRELLA AND EXCESS LIABILITY (AB 90 51 03 99) AB9143 02-96 WATER DAMAGE ENDORSEMENT (AB 91 43 02 96) AB9149 07-98 DEDUCTIBLE AMENDMENT ENDORSEMENT (AB 91 49 07 98) AB9174 03-99 PROFESSIONAL SERVICES EXCLUSION (AB 91 74 03 99) AB9187 09-98 VACANCY CLAUSE AMENDATORY ENDORSEMENT (AB 91 87 09 98) AB9189 08-07 ABC MU1,TICOVER (AB 91 89 08 07) AB9204 03-99 CALIFORNIA AMENDATORY (AB 92 04 03 99) AB9245 08-99 EMPLOYMENT PRACTICS EXCLUSION - COVERAGE A (AB 92 45 08 99) AE9287 03-02 DETRIMENTAL CODE EXCLUSION (AB 92 87 03 02) AB9292 04-02 FUNGI EXCLUSION - COVERAGE B (AB 92 92 04 02) AB9305 10-02 EARTHQUAKE (AB 93 05 10 02) AB9308 04-03 REV COVERAGE B PERSONAL INJURY (AB 93 08 04 03R) AB9313 11-03 LOSS PAYMENT ENDORSEMENT (AB 93 13 11 03) AB9322 12-04 VIOLATION OF STATUTES EXCLUSION (E-MAILS, PHONE CALLS OR OTHER METHODS OF SENDING MATERIAL OR INFORMATION) (AB 93 22 12 04) AB9338 01-07 REV DATA COMPROMISE COVERAGE FORM - (AB 93 38 01 07 R) A139359 11-08 IDENTITY RECOVERY COVERAGE FORM (AB 93 59 11 08) AB9406 06-09 VETERINARY COVERAGE PLUS EXTENSION ENDORSEMENT (AB 94 06 06 09) 141872 01-99 VETERINARY FLOOD ENDORSEMENT (141872 01 99) 144612 12-07 VETERINARIAN'S PROFESSIONAL LIABILITY COVERAGE (144612 12 07) 178587 01-15 DISCLOSURE OF PREMIUM AND ESTIMATED PREMIUM FOR CERTIFIED ACTS OF TERRORISM COVERAGE; CAP ON INSURER PARTICIPATION IN PAYMENT OF TERRORISM LOSSES (PURSUANT TO TERRORISM RISK INSURANCE ACT) (178587 01 15) GD - 3 POLICY NUMBER Previous Policy Numbers 8 H4 AZC 80928980 8 H4 AZC 80923515 AMERICAN BUSINESS COVERAGE POLICY GENERAL DECLARATIONS Named Insured and Mailing Address SERRANO ANIMAL & BIRD HOSPITAL, INC. DBA: SERRANO ANIMAL & BIRD HOSPITAL 22377 EL TORO RD LAKE FOREST CA 92630 Producer Name and Address VETERINARY INS., SERVICES CO 1400 RIVER PARK DR STE 180 SACRAMENTO CA 95815 The Named Insured is a(n) CORPORATION Coverage for policies other than WORKERS' COMPENSATION is provided in the following Company: NATIONAL SURETY CORPORATION CHICAGO, IL 60603 A STOCK INSURANCE CO. (07) Commercial Group No. Q48/ Business or Operations of the Named Insured: VETERINARIAN Insurance is provided only under each coverage of this policy or the WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY POLICY listed below, subject otherwise to all the terms and conditions of the General Provisions and of said Coverage(s) or policy having reference thereto. PROPERTY/LIABILITY COVERAGES UMBRELLA AND EXCESS LIABILITY Policy Period (For above coverages) INCEPTION DATE 07-01-19 EXPIRATION DATE 07-01-20 Beginning and Ending at 12:01 A.M., Standard Time at the address of the insured GD - 1 ABC MultiCover - AB 91 89 08 07 This endorsement modifies insurance provided under the following: American Business Coverage Your policy is broadened and clarified as follows: 1. Non Employment Discrimination Liability Unless Personal Injury or Advertising Injury is excluded from this policy: A. Section III - Definitions, Item 17. Personal Injury is amended to include: f. Discrimination B. Section III - Definitions, Item 2. Advertising Injury is amended to include: e. Discrimination C. Section III - Definitions is amended to in- clude: 30. Discrimination means the unlawful treat- ment of individuals based on race, color, ethnic origin, gender, religion, age, or sexual preference. D. Section H - Liability Coverage, Part H. Ex- clusions, Item Lp Personal Injury or Adver- tising Injury is amended to include: (11) Arising out of discrimination directly or indirectly related to the past employ- ment, employment or prospective em- ployment of any person or class of persons by any insured; or (12) Arising out of discrimination directly or indirectly related to the sale, rental, lease or sub -lease or prospective sale, rental, lease or sub -lease of any dwelling, permanent lodging, or premises by or at the direction of any insured; or (13) Arising out of discrimination, if insurance thereof is prohibited by law; or (14) Pines, penalties, specific performance, or injunctions levied or imposed by a go- vernmental entity, or governmental code, law, or statute because of discrimination 2. Blanket Additional Insured Section II - Liability Coverage, Part I. Who Is An Insured, Item 2. is amended to include: f. Any person or organization that you are re- quired by a written insured contract to include as an insured, subject to all of the following provisions: (1) Coverage is limited to their liability aris- ing out of: (a) the ownership, maintenance or use of that part of the premises, or land owned by, rented to, or leased to you; or (b) your ongoing operations performed for that insured; or (c) that insured's financial control of you; or (d) the maintenance, operation or use by you of equipment leased to you by such person(s) or organization(s); or This Form must be attached to Change Endorsement when issued after the policy is written. One of the Fireman's Fund Insurance Companies as named in the policy n, #,) (I & " , Secretary AB9189 8-07 I� (4F_Zee:= President Page 1 of 6 (e) a state or political subdivision per- mit issued to you. (2) Coverage does not apply to any occur- rence or offense: (a) which took place before the exe- cution of, or subsequent to the completion or expiration of, the written insured contract, or (b) which takes place after you cease to be a tenant in that premises. (3) With respect to architects, engineers, or surveyors, coverage does not apply to Bodily Injury, Property Damage, Per- sonal Injury or Advertising Injury arising out of the rendering or the failure to render any professional services by or for you including: (a) The preparing, approving, or failing to prepare or approve maps, draw- ings, opinions, reports, surveys, change orders, designs or specifica- tions; and (b) Supervisory, inspection, or engi- neering services. If an Additional Insured endorsement is attached to this policy that specifically names a person or organization as an insured, then this coverage does not apply to that person or organization. 3. Blanket Additional Insured for Vendors Unless the Products -Completed Operations Haz- ard is excluded from this policy, Section II - Li- ability Coverage, Part I. Who Is an Insured, Item 2. is amended to include: g. Any vendor but only with respect to Bodily Injuryor Property Damage arising out of your products which are distributed or sold in the regular course of the vendor's business, sub- ject to the following additional exclusions: 1. The insurance afforded the vendor does not apply to: a. Bodily Injury or Property Damage for which the vendor is obligated to pay damages by reason of the AB91996-07 N assumption of liability in a contract or agreement. This exclusion does not apply to liability for damages that the vendor would have in the absence of the contract or agree- ment; b. Any express warranty unauthorized by you; c. Any physical or chemical change in the product made intentionally by the vendor; d. Repackaging, unless unpacked solely for the purpose of inspection, dem- onstration, testing, or the substi- tution of parts under instructions from the manufacturer, and then re- packaged in the original container. e. Any failure to make such in- spections, adjustments, tests or ser- vicing as the vendor has agreed to make or normally undertakes to make in the usual course of busi- ness, in connection with the distrib- ution or sale of the products; f. Demonstration, installation, servic- ing or repair operations, except such operations performed at the vendor's premises in connection with the sale of the product; g. Products which, after distribution or sale by you, have been labeled or relabeled or used as a container, part or ingredient of any other thing or substance by or for the vendor. 2. This insurance does not apply to any in- sured person or organization, from whom you have acquired such products, or any ingredient, part or container, en- tering into, accompanying or containing such products. If an Additional Insured - Vendors endorsement is attached to this policy that specifically names a person or organization as an insured, then this coverage does not apply to that person or organ- ization. Page 2 of 6 4. Blanket Waiver of Subrogation Section II - Liability Coverage, Part K. Liability and Medical Payments General Conditions, is amended to include: 6. Transfer of Rights of Recovery Against Oth- ers to us and Blanket Waiver of Subrogation a. If the insured has rights to recover all or part of any payment we have made under this Coverage Part, those rights are transferred to us. The insured must do nothing after loss to impair those rights. At our request, the insured will bring suit or transfer those rights to us and help us enforce them. b. If required by a written insured contract, we waive any right of recovery we may have against any person or organization because of payments we make for injury or damage arising out of your operations or your work for that person or organ- ization. 5. Broadened Named Insured before you acquired or formed the or- ganization; (c) Coverage C does not apply to personal injury or advertising injury arising out of an offense committed before you ac- quired or formed the organization. 6. Medical Payments Unless Coverage D. Medical Payments is excluded from this policy: A. Section II - Liability Coverage, Part H. Ex- clusions, Item 2.f. is replaced with: f. Included within the products -completed operations hazard. However, this exclu- sion does not apply to expenses for den- tal services. B. Section II - Liability Coverage, Part G. Cov- erage, Item 2., is amended to include: c. Coverage D. Medical Payments is pri- mary and not contributing with any other insurance, even if that other insur- ance is primary also. Section II - Liability Coverage, Part I. Who Is An 7. Tenant's Legal Liability Insured, Item 4•. is replaced with: 4. All of your subsidiaries, companies, corpo- A. Section III - Liability Coverage, Part J. Li- ability and Medical Payments Limits of In - rations, firms, or organizations, as now or surance, Item 3. is replaced with: hereafter constituted, qualify as Named In- sured under this policy i£ 3. The most we will pay under Coverage C (a) you have the responsibility of placing in- - Liability for damages because of prop- surance for each such entity; and erty damage to premises while rented to you, temporarily occupied by you with (b) coverage for the entity is not otherwise the permission of the owner, or managed more specifically provided; and by you under a written agreement with the owner: (c) the entity is incorporated or organized under the laws of the United States of a. arising out of any Covered Cause of America. Loss shall be the greater of: But each entity is insured only while you (1) $1,000,000; or own, during the policy period, a controlling (2) The Tenant's Legal Liability interest in such entity of greater than 50% of limit shown in the Declarations. the stock or assets. However: 8. Chartered Aircraft (a) Coverage under this provision is afforded only until the end of the policy period, Section II - Liability Coverage, Coverage C, Part or the 12 month anniversary of the policy H. Exclusions, Item l.g. is amended to include: inception date, whichever is earlier; (5) An aircraft in which you have no ownership (b) Coverage C does not apply to bodily in- interest and that you have chartered with jury or property damage that occurred crew. AB9189 8-07 Page 3 of 6 9. Coverage Territory Broadened Section III - Defimitions, Item 5.a. is replaced with: a. The United States of America (including its territories and possessions), Puerto Rico, Ca- nada, Bermuda, the Bahamas, the Cayman Islands and the British Virgin Islands. 10. Broadened Advertising Injury Unless Advertising Injury is excluded from this policy: A. Section III - Definitions, Item 2. is replaced with: 2. Advertising Injury means injury arising out of one or more of the following of- fenses: a. Oral, written, televised or videotaped publication of material that slanders or libels a person or organization or disparages a person's or organiza- tion's goods, products or services; b. Oral, written, televised or videotaped publication of material that violates a-person's right of privacy; c. Misappropriation of advertising ideas or style of doing business; or d. Infringement of trademark, copy- right, title or slogan. B. Section II - Liability Coverage, Coverage C, Part H. Exclusions, Items l.p.(1) and (2) are replaced with: (1) Arising out of oral, written, televised or videotaped publication of material, if done by or at the direction of the insured with knowledge of its falsity; (2) Arising out of oral, written, televised or videotaped publication of material whose first publication took place before the beginning of the policy period; 11. Broadened Personal Injury Unless Personal Injury is excluded from this pol- icy, Section III - Property, Liability and Medical AB9189 8-07 Payments Definitions, Items 17.b., d. and e. are replaced with: b. Malicious prosecution or abuse of process; d. Oral, written, televised or videotaped publica- tion of material that slanders or libels a person or organization or disparages a person's or organization's goods, products or services; e. Oral, written, televised or videotaped publica- tion of material that violates a person's right of privacy; 12. Broadened Personal or Advertising Injury Unless Personal Injury or Advertising Injury is excluded from this policy, Section II - Liability Coverage, Coverage C, Part H. Exclusions, Item l.p.(4) Exclusions is deleted in its entirety. 13. Fellow Employees Coverage Section II - Liability Coverage, Part I. Who Is an Insured, Item 2.a.(1) is amended as follows: (1) Personal Injury to you or to a co -employee while in the course of his or her employment, or the spouse, child, fetus, embryo, parent, brother, sister or any member of the house- hold of that employee or co -employee as a consequence of such Personal Injury, or for any obligation to share damages with or repay someone else who must pay damages because of the injury; or 14. Mental Anguish Is Included in Bodily Injury Section III - Definitions, Item 4. is replaced with: 4. Bodily injury means bodily injury, sickness or disease sustained by a person. It includes death or mental anguish which result at any time from such physical harm, physical sick- ness or physical disease. Mental anguish me- ans any type of mental or emotional illness or disease. 15. Unintentional Failure to Disclose Hazards Section II - Liability Coverage, Part K. Liability and Medical Payments General Conditions, is amended to include: Page 4 of 6 6. Unintentional Failure to Disclose Hazards If you unintentionally fail to disclose any ha- zards existing at the inception date of your policy, we will not deny coverage under this Coverage Form because of such failure. However, this provision does not affect our right to collect additional premium or exercise our right of cancellation or non -renewal. legal representatives are aware of the General Liability occurrence, offense, claim, or suit. Knowledge of an occurrence, offense, claim, or suit by other employee(s) does not imply you also have such knowledge. b. To the extent possible, notice to us should include: (1) How, when and where the occurrence or 16. Supplementary Payments, Increase Limits offense took place; Section II - Liability Coverage, Part G. Coverage, Items Le. (2) and (4) are replaced with: (2) The cost of bail bonds required because of accidents or traffic law violations arising out of the use of any vehicle to which the Bodily Injury Liability Coverage applies. We do not have to furnish these bonds. (4) All reasonable expenses incurred by the in- sured at our request to assist us in the inves- tigation or defense of the claim or suit including substantiated loss of earnings up to $500 a day because of time off work. 17. Per Location Aggregate A. Section 11 - Liability Coverage, Part J. Limits of Insurance, Item 4. is amended to include: The Aggregate Limit of Insurance applies se- parately to each location owned by you, rented to you, or occupied by you with the permission of the owner. B. Section III - Property, Liability and Medical Payments Definitions, is amended to include: 31. Location means premises involving the same or connecting lots, or premises whose connection is interrupted only by a street, roadway, waterway or right-of- way of railroad. 18. Amended Duties in the Event of an Occurrence, Offense Claim or Suit Section II - Liability Coverage, Part K. Liability and Medical Payments General Conditions, Items 2.a. and b. are replaced with: a. In the event of an occurrence, offense, claim, or suit, you must promptly notify us. Your duty to promptly notify us is effective when your executive officers, partners, members, or AB9189 8-07 (2) The names, addresses, and telephone numbers of any injured persons and wit- nesses; and (3) The nature and location of any injury or damage arising out of the occurrence, of- fense, claim, or suit. 19. Common Policy Conditions (AB 00 09 A 01 87), Part A. Other Insurance, Item 2. is replaced with: 2. Coverage C - Liability If other valid and collectible insurance is available to any insured for a loss we cover under Coverage C of this Coverage Part our obligations are limited as follows: a. The insurance provided under this policy is primary if you are required by a written Insured contract to include any person or organization as an insured, but only with respect to that insured's liability arising out of the ownership, mainte- nance, or use of that part of the premises owned by or rented to you, or your work for that insured by or for you. Any other insurance available to that person or or- ganization is excess and noncontributory with this insurance, or; b. Except for the circumstance described in 2.a., above, the insurance provided under this policy is excess over any other li- ability insurance available to any insured whether such other insurance is written as primary, excess, contingent or any other basis. An exception applies when any insured specifically has purchased excess insurance to apply in excess of the limits of insurance shown in the Decla- rations of this Coverage Part for Cover- age C. Page 5 of 6 20. Damage to Invitees' Automobiles from Falling Trees or Tree Limbs - Limited Coveragc The policy applies to direct physical damage to automobiles owned by invitees subject to all of the following: 1. Provided such damage originates from prem- ises owned, managed, leased or rented by an insured; 2. Coverage applies only to invitees of an in- sured or an insured's tenant; 3. Such damage is directly caused by wind -driven falling trees or tree limbs; 4. The most we will pay for any one loss is the lesser of the actual cash value of the damaged automobile as of the time of the loss; or the cost of repairing or replacing the damaged automobile with another automobile of like AB9189 8-07 kind and quality; subject to a limit of $25,000 in any one policy period; and 5. This coverage is not subject to the General Liability General Aggregate Limit. 21. Expected or Intended Injury - Amendment to Ex- clusion SECTION I. - 2. EXCLUSIONS a. Expected or Intended Injury, is replaced by the following: a. Expected or Intended Injury Bodily injury or property damage expected or intended from the standpoint of the insured. This exclusion does not apply to bodily injury or property damage resulting from the use of reasonable force to protect persons or prop- erty. All other terms and conditions of the policy apply. Page 6 of 6 CIZXCGCOH 10-07 -06A_ Fireman's F and POLICY NUMBER 8 H4 AZC 8092 89 80 NATIONAL SURETY CORPORATION, CHICAGO, IL (07) Named Insured SERRANO ANIMAL & BIRD HOSPITAL,WELD AMERICAN BUSINESS COVERAGE CHANGE ENDORSEMENT Effective 07/01/19, 12:01 A.M., Standard Time at the address of the insured Sequential Endorsement Number 002 This is an Endorsement only. Other than changes shown, all other pre-existing coverage remains in full force and effect. Premium adjustments are shown. PREMIUM SUMMARY: ADDITIONAL PREMIUM DUE NOW $0.00 Terrorism Risk Insurance Act ("The Act") - Certified Acts Coverage - All Coverages Subject to the Act Excl WC and Umbrella - Covered $0.00 THE FOLLOWING CHANGES APPLY TO PROPERTY/LIABILITY COVERAGE ADDITIONAL INSURED - OWNERS, LESSORS OR CONTRACTORS (AB 90 67 12 93) ENDORSEMENT IS ADDED AND APPLIES AS FOLLOWS: A/I NO. 02 • LOC 002 NAME: CITY OF SANTA ANA ITS OFFICERS, AGENTS AND EMPLOYEES, RISK MANAGEMENT DIVISION STREET: 20 CIVIC CENTER PLAZA, 4TH FLOOR CITY: SANTA ANA ST: CA ZIP CODE: 92702 Forms Added at the Inception of this Change Endorsement PROPERTY/LIABILITY AB9067 12-93 Countersignature of Authorized Agent: Producer VETERINARY INS., SERVICES CO 1400 RIVER PARK DR STE 180 SACRAMENTO CA 95815 E OF CHANGE ENDORSEMENT Date 09/03/19 Page 1 Policy Number: CIZXCSC2 9-94 FIREMAN'S FUND INSURANCE COMPANY SFCIC COMMERCIAL GROUP CENTER 5701 GOLDEN HILLS DRIVE Finemank MINNEAPOLIS MN 55416 Fund SERRANO ANIMAL & BIRD HOSPITAL, INC. DBA: SERRANO ANIMAL & BIRD HOSPITAL 22377 EL TORO RD LAKE FOREST AZC 80928980 CA 92630 Additional Insured - Owners, Lessees or Contractors - AB 90 67 12 93 Policy Amendment Section II Insured Policy Number Producer Effective Date Schedule Name of Person(s) or Organization(s) (If no entry appears above, information required to complete this Endorsement will be shown in the Declarations as applicable to this Endorsement.) The following is added to Part I - WHO IS AN IN- arising out of your work for that insured by or for SURED in the Business Liability Section of this policy you. 5. The person or organization shown in the Schedule is also an insured, but only with respect to liability All other terms and conditions of the policy apply. This Form must be attached to Change Endorsement when issued after the policy is written. One of the Fireman's Fund Insurance Companies as named in the policy Secretary AB9067 12-93 Contains copyrighted Material of Insurance ServicesOf►Ice, Inc., 9 4 /2- e! P ident _—IMIRIP SERRANI-01 DTHOMAS 11*. 914/2 � 7" CERTIFICATE OF LIABILITY INSURANCE DATE D/YYYY) `� r4rzo19 THIS CERTIFICATE IS 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. r— 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 C NTACT Dian Thomas Veterinary Insurance Services Company PHONE No, Ext : arc No :(918 921-2266 1400 River Park Drive, #180 Sacramento, CA 95815 IA I dthomas@vise-ine.com INS RE AFFORDING COVERAGE AIC # INSURERA.- Allianz Global/ Fireman's Fund INSURED INSURER B:Preferred Employers Ins 10900 Serrano Animal & Bird Hospital, Inc. INSURER C Scott H. Weldy, DVM 21771 Lake Forest Drive #111 INSURER D ; Lake Forest, CA 92630 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 POLICY NUMBER POLICY EFF POLICY EXPLTR LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE OCCUR �( AZC80928980 7/1/2019 7/1/2020 DAMAGE TO RISES (EaENTED 100,000 IRECn =VD /An — nc. % It 10,000 LAGGREGATELIMITAPPLIESPER: GENERAL AGGREGATE $ 2,000,000 POLICY JELQT LOC PRODUCTS - COMP/OP AGG $ 2,000,000 A AUTOMOBILE LIABILITY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS SSWN AUTOS ONLY X AUOTOS ONLY �AZC80928980 7/1/2019 7/1/2020 COMBINED SINGLE LIMIT $ 1,000,000 BODILY INJURY Perperson) $ IxANY BODILY INNJURY Per accident Parlent AMAC3E 4�BRELLA LIAB ESS LIAB CLAIMS -MADE EACH OCCURRENCE HOCCUR E $ RETENTION $ B WORKERS COMPENSATION ANDEMPLOYERS'LIABILITY ApFFICERIMEMBER EXCLUDED ECUTIVE Y� (Mandatory In NH) If Yes, describe under DESCRIPTION OF OPERATIONS below NIA TN164036-3 - 7/1/2019 7/1/2020 X PER TE 07H- STATU ER EL EACH ACCIDENT 1,000,000 $ E.L. DISEASE - EA EMPLOYE $ 1,000,000 E L DISEASE - POLICY LIMIT $ 1,000,600 DESCRIPTION OF DPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) '30 Day's Notice of Cancellation / 10-Days NOC for non-payment. Certificate holder is named as additional insured Per ABC MultiCover AB9189 0807. City of Santa Ana, its officers, agents and employees are included as addtional insureds. REWMED & APPROVED BEHOLDER "r "`' CANCELLATION 7 2019 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Santa Ana THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ty ACCORDANCE WITH THE POLICY PROVISIONS. Risk Management Divlslo A THA M. LAMBERT 20 Civic Center Plaza, 4th Fum Santa Ana, CA 92702 AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD t-aqu I UI L a r(21Nst Century insurance Named Insured and Mailing Address SCOTT WELDY 22671 REVERE RD EL TORO, CA 92630-6000 E-mail: BIGBIRODOGOAOL.COM Vehicle(s) and Driver(el Veh Yew Mokeffilodel 1 61 OTHE VOLVO544 0 - 2 10 CADI CTS PERFORMANCE COSD 3 67 CHEV CAMARO Veh Rated Driver 4 SCOTT WELDY 5 ROBERT WELDY PERSONAL AUTO POLICY DECLARATION 1Vehicle 10 Number A61289410 1G6DJ5EV2A0142094 1243771-159395 J1.1yZanamsad TIcN 45 0 13 0 AMEND - POLICY CHANGE EFFECTIVE 07/24/19 Account: 21ST CENTURY INSURANCE Customer Service Center. 21st CENTURY INSURANCE 21ST CENTURY PLAZA P.O. BOX 15510 WILMINGTON, DE 19850-5510 Policy No: 8377 29 50 Policy Period: From 04130/19 To: 10130/19 12:01 AM Standard Time Ise Vehicle Discounts/Comments Xlp Mileage 07 NICD ADDITIONAL VEH 92630 1.000 P MCD ADDITIONALVEH 92630 9 999 P MCD ADDITION Chargeable Accidents i 92630 1 Driver Discounts GDDISD5 GDDISD5 GUVEKAGE IS PROVIDED WHERE Coverage A PREMIUM AND A LIMIT OF LIABILITY ARE SHOWN FOR THE COVERAGE _ Limit of Liability - Premium Veh 1 Veh 2 Veh 3 A. Hndil� 1%ry Liability $100, 000 each person Includes 0. 8 per vehicle fraud fee $300000 each accident $ 98.00 5 203.00 $ 30.00 B. Piro arty Damage Liability ^i o0 000 each accident $ 27.0_0 S 159.00 V 27. 00 C. Medical Payments $5 000 each 9.00�^ 58.00 $ 9.00 Uninsured Motorist ..person $100,000 each person D. Bodily lniuy $3o0 000 each accident $ 21.00 $ 106.00 $ 21.00 DAMAGE TO YOUR VEHICLE Veh 1 Veh 2 Veh 3 Actual Cash Value Less Deductible Dad. Dad. Dad. • Comprehensive _ ACV_ $500 J $ 2.00 $ 4:3.00 -No Cove F. Collision T $10o $!iUU t y 14.00 $ 376.00Coyy- Uninsured Motorist D1. Prooft 11-am e _ DErD WAIVE I DED WAIVE 1 $3500 MAX $ 2..00 $ 5.00 $` 2.00 Zi ssi Century --- G. Roadside Assistance $75 each disablement Included Included Included Rental Per day $ 2 S Fl. Reimbursement_ max 1 $750 $ o.0i1 19.00 $ 0.00 .i. Additional Equipment _ Inoluded $1 , 000 $1 , 000 The first $1000 is aulcmallcally Additional Included wilh roverappe E or F. Additional cpveraNc a Is optional_ _ Total ; :t, o0a ,1, 000 ± U . 00 $ 0.00 $ 0.00 Total Premium Per Vehicle $ 173. 00 $ 967 .00 $ 89.00 If the installment bill plan is used, a service charge may apply. Total Premium Endomement(sylAgreement(s) AppllcaUkc TCU-1 (01119) TCU511CA (05/18) TCU631CA (02/12) AU CWF9 1011 Loss Payee (LP), Additional Insured (AI) Drivers Not Rated Veh 5 LP NU VISION CU THE POLLOWING FEE(S) MAY APPLY: 07l24/19 LATE: $&.80 PAYMENT RETURNED (NSF): $10.00 �• . CANCEL; $50.00 INSTALLMENT BILL PLAN SERVICE CHAROE:$4.00 Awlimulmi Cvn rM y -q f-d) WHEN ATTACHED TO THE PERSONAL AUTO POLICY. THESE DECLARATIONS COMPLETE THE POLICY AND REPRESENT 1 HE CURRENT STATUS OF YOUR COVERAGES AND LIMITS OF LIABILITY. Visit 21st.com to make policy changes, pay your premium, and more. Register online todayl For Customer Care rail 800-241-1188. TCU41CA (12114) 21st C tury Insurance Company, P.O. Box 15510, Wilmington, DE 19886-5292 1-M rage t ul z O ((21Nst Century insurance - Named Insured and Mailing Address SCOTT WELDY 22671 REVERE RD EL TORO, CA 92630-5000 E-mail: BIGBIRDDOG®AOL.COM Vehlale(s) and DAver(s) Veh ell - 'MatwliVlodel :: -- 4 98 TOYT RAV4 ar - 5 18 FORD F150 RAPTOR PK vdr Rifted driver PERSONAL AUTO POLICY DECLARATION AMEND - POLICY CHANGE EFFECTIVE 07/24/19 Account: 21 ST CENTURY INSURANCE Customer Service Center: 21st CENTURY INSURANCE 21ST CENTURY PLAZA P.O. BOX 15510 WILMINGTON, DE 19850-5510 Policy No: 8377 29 50 Policy Period: From 04130119 To: 10/30/19 12:01 AM Standard Time Vehlcle ID Number llae Vehicle Dlaco "WC-ommerrts: zip.,- I Mileage o JT3HP10VOW7096930 W MGM 92630 7,201 1 FTFW 1 RG3JFA96316 P MCD4ATD 92630 9.999 D WHERE A PRC-MI[1M yearsTlakets Chergeable Acoidents Driver Discounts Llcvnsvdne nF I IARII ITV ARF CHr1WKl FnR TWF r.nVr-QA - Coverage; __. Lhrllt of Llnbllity Premium Veh4 Vah 5 A. Badi1 Injury t €ability includes 0. 8 per fraud fee _-- _ __- B. Property Damage Liabitity _ Medical Payments $100, 000 each person Saoo, 000 each accident c � 9s.00 S 149.00 _ sloo 000 . _ _e ch_accident _ _. $S 000 _ Wch perawn $,_ 93.00 $ 22.00 122.00 S s3. 00 Uninsured Motorist D. Badl_Injury _ DAMAGE TO YOUR VEHICLE Actual Cash Value Less Deductible $100, 000 each person .5300, 000 each accident Veh 4 Vet+ 6 S 45.00 $ 1-1.00 _$ 84.00 �! $ '10.00 Dad. Ded. E. Comprehensive $100 $500 F. Collision Uninsured Property Damage $100 $500 L)E:!l wAxvir DEL) WATVC $75 each disablement $25 $25 ' $150 $750 $ 79.00 $ 307.00 - I $ 2.00_ included $ 5.00 Included - _ 21st Century G. Roadside Assistance_ Rental -- Per day H. Reimbursement_ _ I max J. Additional Equipment The first $1000 is automatically Included with coverage E or F. Additional coverage Is optional, If the installment bill plan is used, a service $ 19.00 $ 19.00 Included Additional Total Total0.00 $1-, 000 $1, 000 $1.1000 $1, 000 S 0.00 Total Premium Per Vehicle 354.00 $ 808.00 Total Premium $ 2,401.00 charge may apply. Endorsement(s)/Agreement(s) Applicable: Drivers Not Rated 07124/19 THE FOLLOWING FEES) MAY APPLY: LATE: $5.00 PAYMENT RETURNED (NSF): $10.00 . CANCEL: $50.00 INSTALLMENT BILL PLAN SERVICE CHARGE,."00 �uAhOifmr! Cwrvnny gntuoeeminllvo {wlxuu m�pdrrnlj WHEN ATTACHED TO THE PERSONAL AUTO POLICY, THESE DECLARATIONS COMPLETE THE POLICY AND REPRESENT THE CURRENT STATUS OF YOUR COVERAGES AND LIMITS OF LIABILITY. Visit 21st.com to make policy changes, pay your premium, and more. Register online today! For Customer Care call 800-241-1188. TCU41CA (12114) 21s1 Cenlury Insurance Company, P.O. Box 15510, Wilmington, DE 10886-5292 A- q_q-r Lambert, Samantha From: Cuevas, Silvia Sent: Tuesday, September 17, 2019 11:40 AM To: Lambert, Samantha Subject: RE: Request for COI Review: Dr. Scott Weldy dba Serrano Animal and Bird Hospital Hi, yes I confirmed with them and they don't own vehicles. They listed the vehicles that would be used and VIN Ws on the insur ce. Thank you Silvia From: Lambert, Samantha <SLambert@santa-ana.org> Sent: Friday, September 13, 2019 8:31 AM To: Cuevas, Silvia <SCuevas@santa-ana.org> Subject: FW: Request for COI Review: Dr. Scott Weldy dba Serrano Animal and Bird Hospital HI Silvia, I see the automobile liability does not include Owned, did you confirm with the insured the company does not own any vehicles? I see they provided their private auto insurance information but I did not want to presume. Samantha M. Lambert I Risk Management Supervisor Human Resources 120 Civic Center Plaza I Santa Ana, CA 92701 714-647-6959 1 slam bert@santa-ana.ore - 2020 -- 2 2„ SANTA ANA COUNTS f http://www.santa-ana.org/ This e-mail (and attachments, if any) may be subject to the California Public Records Act and as such, may, therefore, be subject to public disclosure unless otherwise exempt under the Act. From: Cuevas, Silvia Sent: Thursday, September 05, 2019 10:08 AM To: RMD <RMD@santa-ana.org> Subject: Request for COI Review: Dr. Scott Weldy dba Serrano Animal and Bird Hospital R °guest for COI Review: Department: Parks, Recreation and Community Services Agency POLICY NUMBER 8 H4 AZC 80928980 AMERICAN BUSINESS COVERAGE POLICY Named Insured SERRANO ANIMAL & BIRD HOSPITAL,WELD GENERAL DECLARATIONS Continued FORMS ATTACHED AT INCEPTION GENERAL PROVISIONS AB0009A 01-87 COMMON POLICY CONDITIONS (AB 00 09A 01 87) IL0270 09-12 CALIFORNIA CHANGES - CANCELLATION AND NONRENEWAL (IL 02 70 09 12) 143003 11-85 DIVIDEND PROVISIONS (143003 11-85) 145917CA 06-04 SILICA PARTICLES EXCLUSION - CALIFORNIA (145917CA 06 04) 145927 01-15 DISCLOSURE OF PREMIUM AND ESTIMATED PREMIUM FOR CERTIFIED ACTS OF TERRORISM COVERAGE (PURSUANT TO TERRORISM RISK INSURANCE ACT) (145927 01 15) 145983 10-13 CIVIL UNION AMENDATORY ENDORSEMENT (145983 10 13) 145985 06-14 ECONOMIC OR TRADE SANCTIONS COMPLIANCE (145985 06 14) PROPERTY/LIABILITY AB0404A 01-87 HIRED AUTO AND NON -OWNED LIABILITY (AB 04 04A 01 87) AB1203 11-94 LOSS PAYABLE PROVISION (AB 12 03 11 94) AB9000 12-93 REV 2 PROPERTY/LIABILITY POLICY (AB 90 00 12 93S) AB9017 06-09 MECHANICAL, ELECTRICAL AND PRESSURE EQUIPMENT COVERAGE ENDORSEMENT (AB 90 17 06 09) AB9051 03-99 UMBRELLA AND EXCESS LIABILITY (AB 90 51 03 99) AB9143 02-96 WATER DAMAGE ENDORSEMENT (AB 91 43 02 96) AB9149 07-98 DEDUCTIBLE AMENDMENT ENDORSEMENT (AB 91 49 07 98) AB9174 03-99 PROFESSIONAL SERVICES EXCLUSION (AB 91 74 03 99) AB9187 09-98 VACANCY CLAUSE AMENDATORY ENDORSEMENT (AB 91 87 09 98) AB9189 08-07 ABC MU1,TICOVER (AB 91 89 08 07) AB9204 03-99 CALIFORNIA AMENDATORY (AB 92 04 03 99) AB9245 08-99 EMPLOYMENT PRACTICS EXCLUSION - COVERAGE A (AB 92 45 08 99) AE9287 03-02 DETRIMENTAL CODE EXCLUSION (AB 92 87 03 02) AB9292 04-02 FUNGI EXCLUSION - COVERAGE B (AB 92 92 04 02) AB9305 10-02 EARTHQUAKE (AB 93 05 10 02) AB9308 04-03 REV COVERAGE B PERSONAL INJURY (AB 93 08 04 03R) AB9313 11-03 LOSS PAYMENT ENDORSEMENT (AB 93 13 11 03) AB9322 12-04 VIOLATION OF STATUTES EXCLUSION (E-MAILS, PHONE CALLS OR OTHER METHODS OF SENDING MATERIAL OR INFORMATION) (AB 93 22 12 04) AB9338 01-07 REV DATA COMPROMISE COVERAGE FORM - (AB 93 38 01 07 R) A139359 11-08 IDENTITY RECOVERY COVERAGE FORM (AB 93 59 11 08) AB9406 06-09 VETERINARY COVERAGE PLUS EXTENSION ENDORSEMENT (AB 94 06 06 09) 141872 01-99 VETERINARY FLOOD ENDORSEMENT (141872 01 99) 144612 12-07 VETERINARIAN'S PROFESSIONAL LIABILITY COVERAGE (144612 12 07) 178587 01-15 DISCLOSURE OF PREMIUM AND ESTIMATED PREMIUM FOR CERTIFIED ACTS OF TERRORISM COVERAGE; CAP ON INSURER PARTICIPATION IN PAYMENT OF TERRORISM LOSSES (PURSUANT TO TERRORISM RISK INSURANCE ACT) (178587 01 15) GD - 3 POLICY NUMBER Previous Policy Numbers 8 H4 AZC 80928980 8 H4 AZC 80923515 AMERICAN BUSINESS COVERAGE POLICY GENERAL DECLARATIONS Named Insured and Mailing Address SERRANO ANIMAL & BIRD HOSPITAL, INC. DBA: SERRANO ANIMAL & BIRD HOSPITAL 22377 EL TORO RD LAKE FOREST CA 92630 Producer Name and Address VETERINARY INS., SERVICES CO 1400 RIVER PARK DR STE 180 SACRAMENTO CA 95815 The Named Insured is a(n) CORPORATION Coverage for policies other than WORKERS' COMPENSATION is provided in the following Company: NATIONAL SURETY CORPORATION CHICAGO, IL 60603 A STOCK INSURANCE CO. (07) Commercial Group No. Q48/ Business or Operations of the Named Insured: VETERINARIAN Insurance is provided only under each coverage of this policy or the WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY POLICY listed below, subject otherwise to all the terms and conditions of the General Provisions and of said Coverage(s) or policy having reference thereto. PROPERTY/LIABILITY COVERAGES UMBRELLA AND EXCESS LIABILITY Policy Period (For above coverages) INCEPTION DATE 07-01-19 EXPIRATION DATE 07-01-20 Beginning and Ending at 12:01 A.M., Standard Time at the address of the insured GD - 1 ABC MultiCover - AB 91 89 08 07 This endorsement modifies insurance provided under the following: American Business Coverage Your policy is broadened and clarified as follows: 1. Non Employment Discrimination Liability Unless Personal Injury or Advertising Injury is excluded from this policy: A. Section III - Definitions, Item 17. Personal Injury is amended to include: f. Discrimination B. Section III - Definitions, Item 2. Advertising Injury is amended to include: e. Discrimination C. Section III - Definitions is amended to in- clude: 30. Discrimination means the unlawful treat- ment of individuals based on race, color, ethnic origin, gender, religion, age, or sexual preference. D. Section H - Liability Coverage, Part H. Ex- clusions, Item Lp Personal Injury or Adver- tising Injury is amended to include: (11) Arising out of discrimination directly or indirectly related to the past employ- ment, employment or prospective em- ployment of any person or class of persons by any insured; or (12) Arising out of discrimination directly or indirectly related to the sale, rental, lease or sub -lease or prospective sale, rental, lease or sub -lease of any dwelling, permanent lodging, or premises by or at the direction of any insured; or (13) Arising out of discrimination, if insurance thereof is prohibited by law; or (14) Pines, penalties, specific performance, or injunctions levied or imposed by a go- vernmental entity, or governmental code, law, or statute because of discrimination 2. Blanket Additional Insured Section II - Liability Coverage, Part I. Who Is An Insured, Item 2. is amended to include: f. Any person or organization that you are re- quired by a written insured contract to include as an insured, subject to all of the following provisions: (1) Coverage is limited to their liability aris- ing out of: (a) the ownership, maintenance or use of that part of the premises, or land owned by, rented to, or leased to you; or (b) your ongoing operations performed for that insured; or (c) that insured's financial control of you; or (d) the maintenance, operation or use by you of equipment leased to you by such person(s) or organization(s); or This Form must be attached to Change Endorsement when issued after the policy is written. One of the Fireman's Fund Insurance Companies as named in the policy n, #,) (I & " , Secretary AB9189 8-07 I� (4F_Zee:= President Page 1 of 6 (e) a state or political subdivision per- mit issued to you. (2) Coverage does not apply to any occur- rence or offense: (a) which took place before the exe- cution of, or subsequent to the completion or expiration of, the written insured contract, or (b) which takes place after you cease to be a tenant in that premises. (3) With respect to architects, engineers, or surveyors, coverage does not apply to Bodily Injury, Property Damage, Per- sonal Injury or Advertising Injury arising out of the rendering or the failure to render any professional services by or for you including: (a) The preparing, approving, or failing to prepare or approve maps, draw- ings, opinions, reports, surveys, change orders, designs or specifica- tions; and (b) Supervisory, inspection, or engi- neering services. If an Additional Insured endorsement is attached to this policy that specifically names a person or organization as an insured, then this coverage does not apply to that person or organization. 3. Blanket Additional Insured for Vendors Unless the Products -Completed Operations Haz- ard is excluded from this policy, Section II - Li- ability Coverage, Part I. Who Is an Insured, Item 2. is amended to include: g. Any vendor but only with respect to Bodily Injuryor Property Damage arising out of your products which are distributed or sold in the regular course of the vendor's business, sub- ject to the following additional exclusions: 1. The insurance afforded the vendor does not apply to: a. Bodily Injury or Property Damage for which the vendor is obligated to pay damages by reason of the AB91996-07 N assumption of liability in a contract or agreement. This exclusion does not apply to liability for damages that the vendor would have in the absence of the contract or agree- ment; b. Any express warranty unauthorized by you; c. Any physical or chemical change in the product made intentionally by the vendor; d. Repackaging, unless unpacked solely for the purpose of inspection, dem- onstration, testing, or the substi- tution of parts under instructions from the manufacturer, and then re- packaged in the original container. e. Any failure to make such in- spections, adjustments, tests or ser- vicing as the vendor has agreed to make or normally undertakes to make in the usual course of busi- ness, in connection with the distrib- ution or sale of the products; f. Demonstration, installation, servic- ing or repair operations, except such operations performed at the vendor's premises in connection with the sale of the product; g. Products which, after distribution or sale by you, have been labeled or relabeled or used as a container, part or ingredient of any other thing or substance by or for the vendor. 2. This insurance does not apply to any in- sured person or organization, from whom you have acquired such products, or any ingredient, part or container, en- tering into, accompanying or containing such products. If an Additional Insured - Vendors endorsement is attached to this policy that specifically names a person or organization as an insured, then this coverage does not apply to that person or organ- ization. Page 2 of 6 4. Blanket Waiver of Subrogation Section II - Liability Coverage, Part K. Liability and Medical Payments General Conditions, is amended to include: 6. Transfer of Rights of Recovery Against Oth- ers to us and Blanket Waiver of Subrogation a. If the insured has rights to recover all or part of any payment we have made under this Coverage Part, those rights are transferred to us. The insured must do nothing after loss to impair those rights. At our request, the insured will bring suit or transfer those rights to us and help us enforce them. b. If required by a written insured contract, we waive any right of recovery we may have against any person or organization because of payments we make for injury or damage arising out of your operations or your work for that person or organ- ization. 5. Broadened Named Insured before you acquired or formed the or- ganization; (c) Coverage C does not apply to personal injury or advertising injury arising out of an offense committed before you ac- quired or formed the organization. 6. Medical Payments Unless Coverage D. Medical Payments is excluded from this policy: A. Section II - Liability Coverage, Part H. Ex- clusions, Item 2.f. is replaced with: f. Included within the products -completed operations hazard. However, this exclu- sion does not apply to expenses for den- tal services. B. Section II - Liability Coverage, Part G. Cov- erage, Item 2., is amended to include: c. Coverage D. Medical Payments is pri- mary and not contributing with any other insurance, even if that other insur- ance is primary also. Section II - Liability Coverage, Part I. Who Is An 7. Tenant's Legal Liability Insured, Item 4•. is replaced with: 4. All of your subsidiaries, companies, corpo- A. Section III - Liability Coverage, Part J. Li- ability and Medical Payments Limits of In - rations, firms, or organizations, as now or surance, Item 3. is replaced with: hereafter constituted, qualify as Named In- sured under this policy i£ 3. The most we will pay under Coverage C (a) you have the responsibility of placing in- - Liability for damages because of prop- surance for each such entity; and erty damage to premises while rented to you, temporarily occupied by you with (b) coverage for the entity is not otherwise the permission of the owner, or managed more specifically provided; and by you under a written agreement with the owner: (c) the entity is incorporated or organized under the laws of the United States of a. arising out of any Covered Cause of America. Loss shall be the greater of: But each entity is insured only while you (1) $1,000,000; or own, during the policy period, a controlling (2) The Tenant's Legal Liability interest in such entity of greater than 50% of limit shown in the Declarations. the stock or assets. However: 8. Chartered Aircraft (a) Coverage under this provision is afforded only until the end of the policy period, Section II - Liability Coverage, Coverage C, Part or the 12 month anniversary of the policy H. Exclusions, Item l.g. is amended to include: inception date, whichever is earlier; (5) An aircraft in which you have no ownership (b) Coverage C does not apply to bodily in- interest and that you have chartered with jury or property damage that occurred crew. AB9189 8-07 Page 3 of 6 9. Coverage Territory Broadened Section III - Defimitions, Item 5.a. is replaced with: a. The United States of America (including its territories and possessions), Puerto Rico, Ca- nada, Bermuda, the Bahamas, the Cayman Islands and the British Virgin Islands. 10. Broadened Advertising Injury Unless Advertising Injury is excluded from this policy: A. Section III - Definitions, Item 2. is replaced with: 2. Advertising Injury means injury arising out of one or more of the following of- fenses: a. Oral, written, televised or videotaped publication of material that slanders or libels a person or organization or disparages a person's or organiza- tion's goods, products or services; b. Oral, written, televised or videotaped publication of material that violates a-person's right of privacy; c. Misappropriation of advertising ideas or style of doing business; or d. Infringement of trademark, copy- right, title or slogan. B. Section II - Liability Coverage, Coverage C, Part H. Exclusions, Items l.p.(1) and (2) are replaced with: (1) Arising out of oral, written, televised or videotaped publication of material, if done by or at the direction of the insured with knowledge of its falsity; (2) Arising out of oral, written, televised or videotaped publication of material whose first publication took place before the beginning of the policy period; 11. Broadened Personal Injury Unless Personal Injury is excluded from this pol- icy, Section III - Property, Liability and Medical AB9189 8-07 Payments Definitions, Items 17.b., d. and e. are replaced with: b. Malicious prosecution or abuse of process; d. Oral, written, televised or videotaped publica- tion of material that slanders or libels a person or organization or disparages a person's or organization's goods, products or services; e. Oral, written, televised or videotaped publica- tion of material that violates a person's right of privacy; 12. Broadened Personal or Advertising Injury Unless Personal Injury or Advertising Injury is excluded from this policy, Section II - Liability Coverage, Coverage C, Part H. Exclusions, Item l.p.(4) Exclusions is deleted in its entirety. 13. Fellow Employees Coverage Section II - Liability Coverage, Part I. Who Is an Insured, Item 2.a.(1) is amended as follows: (1) Personal Injury to you or to a co -employee while in the course of his or her employment, or the spouse, child, fetus, embryo, parent, brother, sister or any member of the house- hold of that employee or co -employee as a consequence of such Personal Injury, or for any obligation to share damages with or repay someone else who must pay damages because of the injury; or 14. Mental Anguish Is Included in Bodily Injury Section III - Definitions, Item 4. is replaced with: 4. Bodily injury means bodily injury, sickness or disease sustained by a person. It includes death or mental anguish which result at any time from such physical harm, physical sick- ness or physical disease. Mental anguish me- ans any type of mental or emotional illness or disease. 15. Unintentional Failure to Disclose Hazards Section II - Liability Coverage, Part K. Liability and Medical Payments General Conditions, is amended to include: Page 4 of 6 6. Unintentional Failure to Disclose Hazards If you unintentionally fail to disclose any ha- zards existing at the inception date of your policy, we will not deny coverage under this Coverage Form because of such failure. However, this provision does not affect our right to collect additional premium or exercise our right of cancellation or non -renewal. legal representatives are aware of the General Liability occurrence, offense, claim, or suit. Knowledge of an occurrence, offense, claim, or suit by other employee(s) does not imply you also have such knowledge. b. To the extent possible, notice to us should include: (1) How, when and where the occurrence or 16. Supplementary Payments, Increase Limits offense took place; Section II - Liability Coverage, Part G. Coverage, Items Le. (2) and (4) are replaced with: (2) The cost of bail bonds required because of accidents or traffic law violations arising out of the use of any vehicle to which the Bodily Injury Liability Coverage applies. We do not have to furnish these bonds. (4) All reasonable expenses incurred by the in- sured at our request to assist us in the inves- tigation or defense of the claim or suit including substantiated loss of earnings up to $500 a day because of time off work. 17. Per Location Aggregate A. Section 11 - Liability Coverage, Part J. Limits of Insurance, Item 4. is amended to include: The Aggregate Limit of Insurance applies se- parately to each location owned by you, rented to you, or occupied by you with the permission of the owner. B. Section III - Property, Liability and Medical Payments Definitions, is amended to include: 31. Location means premises involving the same or connecting lots, or premises whose connection is interrupted only by a street, roadway, waterway or right-of- way of railroad. 18. Amended Duties in the Event of an Occurrence, Offense Claim or Suit Section II - Liability Coverage, Part K. Liability and Medical Payments General Conditions, Items 2.a. and b. are replaced with: a. In the event of an occurrence, offense, claim, or suit, you must promptly notify us. Your duty to promptly notify us is effective when your executive officers, partners, members, or AB9189 8-07 (2) The names, addresses, and telephone numbers of any injured persons and wit- nesses; and (3) The nature and location of any injury or damage arising out of the occurrence, of- fense, claim, or suit. 19. Common Policy Conditions (AB 00 09 A 01 87), Part A. Other Insurance, Item 2. is replaced with: 2. Coverage C - Liability If other valid and collectible insurance is available to any insured for a loss we cover under Coverage C of this Coverage Part our obligations are limited as follows: a. The insurance provided under this policy is primary if you are required by a written Insured contract to include any person or organization as an insured, but only with respect to that insured's liability arising out of the ownership, mainte- nance, or use of that part of the premises owned by or rented to you, or your work for that insured by or for you. Any other insurance available to that person or or- ganization is excess and noncontributory with this insurance, or; b. Except for the circumstance described in 2.a., above, the insurance provided under this policy is excess over any other li- ability insurance available to any insured whether such other insurance is written as primary, excess, contingent or any other basis. An exception applies when any insured specifically has purchased excess insurance to apply in excess of the limits of insurance shown in the Decla- rations of this Coverage Part for Cover- age C. Page 5 of 6 20. Damage to Invitees' Automobiles from Falling Trees or Tree Limbs - Limited Coveragc The policy applies to direct physical damage to automobiles owned by invitees subject to all of the following: 1. Provided such damage originates from prem- ises owned, managed, leased or rented by an insured; 2. Coverage applies only to invitees of an in- sured or an insured's tenant; 3. Such damage is directly caused by wind -driven falling trees or tree limbs; 4. The most we will pay for any one loss is the lesser of the actual cash value of the damaged automobile as of the time of the loss; or the cost of repairing or replacing the damaged automobile with another automobile of like AB9189 8-07 kind and quality; subject to a limit of $25,000 in any one policy period; and 5. This coverage is not subject to the General Liability General Aggregate Limit. 21. Expected or Intended Injury - Amendment to Ex- clusion SECTION I. - 2. EXCLUSIONS a. Expected or Intended Injury, is replaced by the following: a. Expected or Intended Injury Bodily injury or property damage expected or intended from the standpoint of the insured. This exclusion does not apply to bodily injury or property damage resulting from the use of reasonable force to protect persons or prop- erty. All other terms and conditions of the policy apply. Page 6 of 6 CIZXCGCOH 10-07 -06A_ Fireman's F and POLICY NUMBER 8 H4 AZC 8092 89 80 NATIONAL SURETY CORPORATION, CHICAGO, IL (07) Named Insured SERRANO ANIMAL & BIRD HOSPITAL,WELD AMERICAN BUSINESS COVERAGE CHANGE ENDORSEMENT Effective 07/01/19, 12:01 A.M., Standard Time at the address of the insured Sequential Endorsement Number 002 This is an Endorsement only. Other than changes shown, all other pre-existing coverage remains in full force and effect. Premium adjustments are shown. PREMIUM SUMMARY: ADDITIONAL PREMIUM DUE NOW $0.00 Terrorism Risk Insurance Act ("The Act") - Certified Acts Coverage - All Coverages Subject to the Act Excl WC and Umbrella - Covered $0.00 THE FOLLOWING CHANGES APPLY TO PROPERTY/LIABILITY COVERAGE ADDITIONAL INSURED - OWNERS, LESSORS OR CONTRACTORS (AB 90 67 12 93) ENDORSEMENT IS ADDED AND APPLIES AS FOLLOWS: A/I NO. 02 • LOC 002 NAME: CITY OF SANTA ANA ITS OFFICERS, AGENTS AND EMPLOYEES, RISK MANAGEMENT DIVISION STREET: 20 CIVIC CENTER PLAZA, 4TH FLOOR CITY: SANTA ANA ST: CA ZIP CODE: 92702 Forms Added at the Inception of this Change Endorsement PROPERTY/LIABILITY AB9067 12-93 Countersignature of Authorized Agent: Producer VETERINARY INS., SERVICES CO 1400 RIVER PARK DR STE 180 SACRAMENTO CA 95815 E OF CHANGE ENDORSEMENT Date 09/03/19 Page 1 Policy Number: CIZXCSC2 9-94 FIREMAN'S FUND INSURANCE COMPANY SFCIC COMMERCIAL GROUP CENTER 5701 GOLDEN HILLS DRIVE Finemank MINNEAPOLIS MN 55416 Fund SERRANO ANIMAL & BIRD HOSPITAL, INC. DBA: SERRANO ANIMAL & BIRD HOSPITAL 22377 EL TORO RD LAKE FOREST AZC 80928980 CA 92630 Additional Insured - Owners, Lessees or Contractors - AB 90 67 12 93 Policy Amendment Section II Insured Policy Number Producer Effective Date Schedule Name of Person(s) or Organization(s) (If no entry appears above, information required to complete this Endorsement will be shown in the Declarations as applicable to this Endorsement.) The following is added to Part I - WHO IS AN IN- arising out of your work for that insured by or for SURED in the Business Liability Section of this policy you. 5. The person or organization shown in the Schedule is also an insured, but only with respect to liability All other terms and conditions of the policy apply. This Form must be attached to Change Endorsement when issued after the policy is written. One of the Fireman's Fund Insurance Companies as named in the policy Secretary AB9067 12-93 Contains copyrighted Material of Insurance ServicesOf►Ice, Inc., 9 4 /2- e! P ident