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HomeMy WebLinkAboutCASA DE LA FAMILIA (2)VIM 2 � 1pti0 MAYOR Miguel A. Pulido MAYOR PRO TEM Juan Villages COUNCILMEMBERS Phil Bacerra Nelida Mendoza David Penaloza Vicente Sarmiento Jose Solorio ,r•SU AIICEONFI— NORK MAY PROCEEC UNTIL INSURANCE EXPIRES CLERK OF COUNCL .ATE. b P0D)U(A"tte Casa de In Familia Attn: Ana Nogales 1650 E. 41' Street Santa Ana, CA 92701 CITY OF SANTA ANA SANTA ANA POLICE DEPARTMENT 60 Civic Center Plaza Santa Ana, California 92701 W WrW.santa-ana.orn October 15, 2020 Re: First Extension of Agreement #A-2020-110 Dear Ms. Nogales, A-2020-110-01 CITY MANAGER Kristine Ridge CITY ATTORNEY Sonia R. Carvalho CLERK OF THE COUNCIL Daisy Gomez Pursuant to Section 3 ("Term") of Agreement No. A-2020-110 ("Agreement") entered into by Casa de Is Familia and the City of Santa Ana, dated June 2, 2020, the parties agree to exercise the first option to extend the term of said Agreement for an additional six (6) months, from January 1, 2021 to June 30, 2021. The insurance certificates are required to be extended and/or renewed to cover this extension. All other terms and conditions of said Agreement remain unchanged and in full force and effect. Davi entin Cliief of Police CITY OF SANTA ANA: Kristine Ridge City Manager APPROVED AS TO FORM: Sonia R. Carvalho i I A ttorney Wl � Tamara Bogosian Senior Assistant City Attorney CASA DE LA FAMILIA ILW # By: Kann.Palma-Rojas Title:.«a.praa Pappas. as ATTEST: Q Daisy Gome Clerk of the 'ouncil SANTA ANA CITY COUNCIL Miguel A. Pulido Juanvillegas viceMe sarmienlo DaNd Penaloze Jose SoloM Phil Bacena handle Mendoza Mayor Mayor Pm Turn, Ward 5 Ward Ward Ward Ward Ward moulldorp}aapla-ana om INIIepazA... W.rao Kanaenlna}aanla-and" doenalozaaearla-anaom eoloro(Isanla-ana.om pOaCaTdQasanla-ana one mepdpZd(-adnlaana oN ACCM o® CERTIFICATE OF LIABILITY INSURANCE DATE(MMNOIYYYY) s124/2020 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. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must 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 Van Wagner Agency 135 Crossways Park Drive P.O. Box 9017 CONT CT PHONE FAX 800-735-1588 x : 868-290-0302 EJAAII vanwa nerinsurance stedin risk.com Woodbury NY 11797 INSURER(S) AFFORDING COVERAGE NAICN INSURER A: Great American Assurance Company 26344 bcensek_ BR-1418528 INSURED CASADE1,01 INSURER 8: Casa De La Familia Karin Palma -Rojas INSURER C Karma Palma -Rojas INSURER D: 1650 E. 4th Street #101 Santa Ana CA 92701 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: 1207416509 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 LTA TYPE OF INSURANCE AO L e POLICY NUMBER MW�DYEYY PMID�� LIMITS A X COMMERCIALGENERALLUBILITY CIAIMS.MADE Q OCCUR Y Y GIP 42&3 "5 5162020 5"2021 ✓ EACH OCCURRENCE sI'Vea000 s� 0 Mu 0 rt n $100,000 MED EXP M one person $5.000 PERSONAL B ADV INJURY $1,000,000 GENE AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $3.000,000 X POLICY ❑ jECOT LOC PRODUCTS-COMPIOPAGG $3.W0,000 S OTHER' AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident) $ BODILY INJURY(Perp.rum) S ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per ac dem) $ PROPERTY DAMAGE P $ NON -OWNED HIREDAUTOS HAUTOS $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAR CLAIMS.MADE DED I I RETENTIONS Is WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN PSTEARTURE ERµ ANY PROPRIETOPoPARTNEWEXECUTIVE E.L. EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED. ❑NIA EL DISEASE - EA EMPLOYE $ (Mandator, In NH) Rryas.describaunder DESCRIPTON OF OPERATIONS below E.L. DISEASE -POLICY LIMIT I $ A Pmless,cral Lunelity / GLP 42933 W 5182mo SIBr2021 Each Indent S1,DOO= / Aggregate 53000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be anached N more space/ Is reaulred)����� p An(]n(1�)['1 City of Santa Ana, officers, employees, agents, volunteers, and representatives are named as additionally insured on a0$ IdLvtlTiall.tdlT ut, agreement, or memorandum of understanding. Such insurance as is afforded by this policy shall be primary, and any I WRM W�hlqq.1bYArmNdd$4��J#Sldffess and noncontributory. L'�T Certificate of Insurance shall provide thirty (30) day prior written notice of cancellation. ✓ JU 2920AL TVFdo CERTIFICATE HOLDER CANCELLATION / ✓ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Santa Ana ACCORDANCE WITH THE POLICY PROVISIONS. Risk Management Division AUTHORIZED REPRESENTATIVE 20 Civic Center Plaza, 4th floor Santa Ana CA 92701 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD IIM AC o)Rht CERTIFICATE OF LIABILITY INSURANCE ATE(M" N 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. IMPORTANT: H the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WANED, 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 Tom Saumur Insurance Agency 4242 Obispo Ave Lakewood CA 90712 CO NAME PHONE PAX ac Not. EMAIL AD ESS� INSURERS AFFORDING COVERAGE NAIC# INSURER A :State Fund INSURED Casa De La Familia Inc INSURER B; 1650 E 4th St INSURER c Hudson Insurance INSURER 0: Santa Ana Ca 92701 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 TR TYPEOFINSURANCE ADDL Mean UBR WVn POLICYNUMBER POLICY EFF D Ir POLICY EXP MM D(YYYYI LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ PREMISES Ee oxam nce $ CLAIMS -MADE ❑ OCCUR MED EXP JAry oneperson) S PERSONAL A ADV INJURY 5 GEML AGGREGATE LIMIT APPLIES PER. GENERALAGGREGATE 3 POLICY 0 JE'T LOC PRODUCTS -COMPIOP AGO S 5 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident S BODILY INJURY (Per person) S ANY AUTO OWNED AUTOS ONLY BODILY INJURY(Per accident) 5 PROPERTY DAMAGE (Per acial S HIRED AUTOS ONLY tC�IMS-�DE UMBRELLALUIB EACH OCCURRENCE S AGGREGATE 5 EXCESSUAS DED I RETENTION 5 S Z A WORKERS COMPENSATION ( I PER OTH- AND EMPLOYERS' LIABILITY ANYPROPRIETORIPARTNER/EXECUTIVE YIN OFFICERMEMBEREXCLUDED? (Mandatory In NH) NIA 248318-19 3l23/2020 3I23/2D21 E.L. EACH ACCIDENT 51,000,000 E.L. DISEASE -EA EMPLOYEE $1,000,000 E.L. DISEASE -POLICY LIMIT S1,009,000 If yes, describe under DESCRIPTION OF OPERATIONS below C Employer Liability 100,000 Retention Includes -Sexual Misconduct Liability FP-HN-NPP-3783 2/1712019 1211712020 1,000,000 Aggregate —11 Employer Practices DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101. Additional Remarks Schedule, may be attached if more space is required) REVIEWED & APPROVE By RISk MANACIEMENT DIVISI ertificate Holder Listed as Additional Insured JUL 0 2020 CERTIFICATE HOLDER CANCELLATION Ah,;r, Arrvcrin iof Santa Ana SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Risk Management Divison THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 0 Civic Center Plaza 4Th Floor ACCORDANCE WITH THE POLICY PROVISIONS. Santa Ana, Ca 92701 AUTHORIZED REPRESENTATIVE 01988.2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Produced using Forma Boss Web software. w FormsBoss.com; If Impresslas Publishing 800-2011-1977 Casa de la Familia Orange County Carnnrate Office- 1650 E 4,h St., Santa Ana, CA 9270 (714)667-5220 508 W Commonwealth Ave., Fullerton, CA 92832 Los Angeles County: 3550 Wilshire Blvd., Ste 670, Los Angeles, CA 90010 (213)413-7777 June 24, 2020 Casa de la Familia requires every employee who drives a motor vehicle as part of his or her job duties (whether frequently or infrequently), and every employee who utilizes Casa de la Familia's- provided parking to maintain current vehicle insurance for at least the minimum liability required by law (as of November 2007, the minimum liability is $15,000 for injury/death of one person; $30,000 for injury/death for more than one person; $5,000 for property damage). The renewal date of an employee's automobile insurance will be noted in his or her personnel file. The employee will be responsible for submitting proof of renewal to Casa de la Familia at each renewal period. Failure to provide proof of renewal by the renewal date will result in immediate suspension of the employee's duties that require the employee to drive a motor vehicle. Respectfully, C&w G9l Karina Palma -Rojas Managing Program Director Casa de la Familia REVIEWED & APPROVED By Risk i1'IANACEMENT DivlsloN JUL �,,2020 AN`giE A�cEvEdo Digitally signed by Francine R. Villareal Francine R. VillarealDate: 2022.01.05 10:15:41 -08'00' DA 7E 4r0,M0I3JYYYYl CERTIFICATE OF LIABILITY INSURANCE 11116021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE, CERTIFICATE HOLDER, THIS CERTIFICATE DOE'S NOT AFFIRMIATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORD15D BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DQF;S NOT CONS71TUTE A CONTRAci BETWEEN THE ISSUING INSURFRS). AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CER111I HOLDER, IMPOIRTAN"r� if bita, cortificite holder is in ADDITIONAL, INSURED, the policy(ies) must boonclorsod, If SUET R00ATION P WAIVED. subject tO the t@rms and conditions of tho plicy, cartalivi policies may requilre an endorsement, A statement, on this cairtificato does apt confer rights to the certificate holder in lieu of such ondorsorri,anilt(s).. PRODUCER I mm . ...................... . ................ I F Van IN89ner Age ricy� PH,0NE I Ael 13 5 Drive . ...................... P.O. Box 901Qste Il-grisk.coin V4v&&-,,u NY 1A 7 W INSURErJs affqrup!raq cOUER E NAIC N . .......................................................... INSURER A: Ci10at Ar'nenzart Assurance Gorrlpny 20'�44 . . . . . . . .......................... . . INWRED CASADEL-01 INSURER B G I 0,3t Army li il,�,kn ITuo orance CArn a 1 Casa De La Fa ills P Karina Palma -Rajas __LN5JRER.C.� . .... .............. Karin@ Pahia-Rojas . . . .. ........................ . ...... i. ........... 1650 E. 4th Street # 101 Ft E R r, &inta An@ CA 92701 ...... . ... . . ...... .. . . . . ......... . . ....... . WSjURER, F � COVERAGES CERTIFICATE NUMBER: 165635(1`17t3 REVISION NUMBER,, THIS IS TO CERTIFY THAT THE PQII(',IE13 OF' INqi,JRANCE LISTED [It.,A.UmV 11AVE BEEN ISSUED TO THE INSURED NAMED ARIDVEI-'01'�, I'ME POLICY PERIOD INOIC'ATED NQTWITHSTANDING ANY RFOUIRCMENT, 11":!I4M OR OL)NDVTION OF ANY CONTRACT OR OTHER DOCUMEATWITH III TOWHICH THIS CERTIFI[t ATE MAY BE 1$,9L1FD OR MAY PERTAIN. THE INSURAINOL AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SIJHJt'0 I to ALL TIi[E TERmS, EXCLLR�10N$ AND CONr)ITIQN$ OF,$1.)CH LIMITSSHOWN MAY HAVEBEEN REDUCED BY PAID CLAIMS. ................ LJA 'TYPE or INSORANC E 1141sb MID POLICY NUMBER �MNJJDDNYYY� 41MMeDWYYYYr A X C OMMURC IAL GC-NeRAL, WARILITY 01. 42 L%23 411 0,1 &W2021 5612022 EACM I CCCLJRREhr.1E I I arml Dou, .. .......... . 7--RRT- GLAfMS-I`.IADE [�] OCCUR -5A "AR 7) IT b ;vIr,01.110 ALE —DE-Y-2-j vn!:O� . ............. i-11L1_1,S0—NAL%±P-V-!NL!yr ......... . . ................. . R1ENI- AV,,bREUATE, LINII r APPLIES FEfik AGGREGATr Lno wl,�,11 G G POLICY JEGr LC{; ori4,p AUTO MOBILE LIABILITY COMBINED . ............ . ANY AL170 . .......... . ... . ALL OWNED SCHEDULED AUTOS AUT05 NON-UlAINED I IREI6AU11 Ti L AUTOS IL4-2 . . ................... . ....... .......... ... . . UMBRELLA LIAD .',C.C UH EAGI I OCCLJRRCNCE ... ......... F XCESS LIAla ACCIREGA7E, . ................ WORKFIR5 CONIPFN9A710N I PER, &ND EMPLOYERS'LIAM) IJIY...................... ......... ANY I-w)H HIF PoH"F-AH I NFH'1FXF(,;W A-'� El EACHACrIDENT $ MEN�IA . ...... .......................... .. I. Mandplrry in Nlk� El DIKIASE - EA EMPU)Yrl,�' .3 ........... . ............... ................ • nr II JR(I" i 0 0 I`� I ID IN S b 0 1 eN E.L. DISF-ASE, POLIcY 0MI r 3 A UtkAly y 'e GLP 429-3.2-4&IM 560321 5.162.012 Each 'YP 22KA9 - v E3 Cybei Uabilk, y y Q u -01 WFiV2921 5M;2022 AIbe,,1MWaN ............. (A,4'QRR t*I. To—&ll.11Ww.'ir i u'tks SeheduAo, onaV be atiazhad If morn space, Is rairwrqap Cily Of Santa Ana, its officors. ornploye-as. agonts, on(j roprnjabve.s are narned as additionally inGLIred on qhiS P,DliCy PUIrij@IjI 1r j t I (IF II contract, agreement, or memorandLIM of understanding. SL,Ich insjrance as is afforded by lkis pol Icy shall be primary, FInd any iPSUrance carried by City sliall bra oxcA�,,s anti norawrvl ribu lory, Certificate of lnsufanco sIrlalil Pfovido thirty t'W) �Iay prior wirlori nofte of cancpJlatiun CERTIFICATE HOLDER CANCELLATION SHIOUL D A NY OF THE ABOVE: DESCRI BE D PO LICIES, 91E AN 1Ie LLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE Wll�l- aE DELIVERED IN City of Santa Ana ACCORDANCE WITH THE, POLICY PROVISION S. Risk Management Division ........................ . ............. 20 Civic Center Plaza, 4th floor AUTHOM2PIJ R:EPq.EqFN7ATTWF Santa Ana CA 92701 Risk MujgmadDMsIcrn 59 198,a.20114 ACORD COF REviEWED&APPROVEDBY: ACORD 2fi (2014101) The ACORD narne and logo are rug istered inarks of ACORD AM= Risk Management Analyst * S1 * 12/21/2021 * GLP-4293348-06-02 GREAT AMERICAN ASSURANCE CO 378559 IL 70 02 (Ed. 10 07) Policy No. GLP 429-33-48 - 06 Effective Date of Change 12/13/2021 POLICY CHANGES NAMED INSURED CASA DE LA FAMILIA AND ADDRESS: 1650 E 4TH STREET 101 SANTA ANA CA 92701 POLICY ALTERNATE MAILING ADDRESS: THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. AGENT'S NAME •ADDRESS:THE VAN WAGNER -y `! BOX 9017 WOODBURY, NY 11797 Insurance is afforded by the Company named below, a Capital Stock Corporation: GREAT AMERICAN ASSURANCE COMPANY POLICY PERIOD: From 05/06/21 To 05/06/22 12:01 A.M. Standard Time at the address of the Named Insured i i�iil�1•C1�:7 cT'/;Ts7:7� �7a��1��1/�17:1:�1r �hl�i�ar�r dai&Mafl0i[il'M&WA]11:1kj1 Vigo iNA 1 • • i FORMS A• ENDORSEMENTS hereby••-• 1 i Agent Signature IL 70 02 (Ed. 10107) PRO (Page 1 of 1) Date o Nye RiskMwaganadDMsian z REVIEWED & APPROVED BY.- 1 Risk Management Analyst °G1°12/21/2O21°GGREAT AMER|CANASSURANCE CO 378559 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organizatiom(s): CITY OF SANTA ANA, ITS 0FFICE&S, OFFICI&LS, EMPLOYEES' AND VOLUNTEERS Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section 88 - Who Is An Insured is amended to include as an additional insured the peroon(o)or organization(s) shown in the Schedu|e, but only with respect to liability for "bodily injury". "property damage" or "personal and advertising injury" ceusmd, in whole or in part, by your acts or omissions or the acts or omissions of those acting onyour behalf: 1. In the performance of your ongoing operations; or 2. In connection with your premises owned by or rented to you. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and O. U coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract oragreement to provide for such additional insured. B. With respect to the insurance afforded to these additional inourmda, the following ioadded to Section UUU ~ Limits Of Insurance: If coverage provided to the additional insured is required by moontract or agreement, the most we will pay on behalf of the Additional Insured is the amount of insurance: 1. Required by the contract or agreement; or @|nsunanoe Services Office, Inc., 2018 RAMwaganadDMsiun Risk Management Analyst * S1 * 12/21/2021 * GLP-4293348-06-02 GREAT AMERICAN ASSURANCE CO 378559 2. Available under the applicable limits of insurance; whichever is less. : III I I I I I I! I I I I T 1 11 11==�=Ii @Insurance Services Office, Inc., 2018 CG 20 26 (Ed. 12119) (Page 2 of 2) o NSF Risk MmaganedDMsiun REVIEWED & APPROVED BY. - Risk Management Analyst * S1 * 03/04/2021 * GLP-4293348-06-02 GREAT AMERICAN ASSURANCE CO 378559 CG 89 47 (Ed. 11 14) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ALLIED HEALTH GENERAL LIABILITY BROADENING ENDORSEMENT This endorsement modifies and is subject to the insurance provided under the following form: COMMERCIAL GENERAL LIABILITY COVERAGE PART This is a summary of the various additional coverages and coverage modifications provided by this endorsement. For complete details on specific coverages, consult the actual policy wording. Coverage Limit of Insurance Page Non -Owned Aircraft Included 2 Non -Owned Watercraft Included 2 Bodily Injury - Mental Injury, Mental Anguish, Humiliation or Shock Included 3 Medical Payments $20,000 3 Damage to Premises Rented to You $1,000,000 3 Supplementary Payments - Bail Bonds $3,000 4 Supplementary Payments - Loss of Earnings $1,000 per day 4 Newly Formed or Acquired Organizations Included 4 Unintentional Failure to Disclose Hazards Included 5 Knowledge of Occurrence, Claim or Suit Included 5 Property Damage Liability - Elevators Included 5 Property Damage Liability - Borrowed Equipment Included 5 Liberalization Clause Included 6 Amendment of Pollution Exclusion (Premises) Included 6 Limited Property Damage to Property of Others $5,000 6 Additional Insured - Manager or Lessor of Premises Included 7 o NSF Risk Management Division z REVIEWED & APPROVED BY.- -��" Risk Management Analyst CG 89 47 (Ed. 11/14) (Page 1 of 12) * S1 * 03/04/2021 * GLP-4293348-06-02 GREAT AMERICAN ASSURANCE CO 378559 Additional Insured - Funding Sources Included 8 Additional Insured - By Contract Included 8 Primary and Non -Contributory Additional Insured Extension Included 10 Additional Insureds - Protection of Your Limits Included 11 Blanket Waiver of Transfer of Rights of Recovery Against Others to Us (Subrogation) Included 11 Property Damage Extension With Voluntary Payments $1,000/$5,000 11 Who Is an Insured - Fellow Employee Extension - Management Employees Included 12 Broadened Personal and Advertising Injury Included 12 A. Non -Owned Aircraft Under paragraph 2. Exclusions of SECTION I - COVERAGE A - Bodily Injury and Property Damage Liability, exclusion g. Aircraft, Auto or Watercraft does not apply to an aircraft provided: 1. it is not owned by any insured; 2. it is hired, chartered or loaned with a trained paid crew; 3. the pilot in command holds a currently effective certificate, issued by the duly constituted authority of the United States of America or Canada, designating him or her a commercial or airline pilot; and 4. it is not being used to carry persons or property for a charge. However, the insurance afforded by this provision does not apply if there is available to the Insured other valid and collectible insurance, whether primary, excess (other than insurance written to apply specifically in excess of this Policy), contingent or on any other basis, that would also apply to the loss covered under this provision. B. Non -Owned Watercraft Under paragraph 2. Exclusions of SECTION I - COVERAGE A - Bodily Injury and Property Damage Liability, subparagraph (2) of exclusion g. Aircraft, Auto or Watercraft is replaced by the following: This exclusion does not apply to: (2) A watercraft you do not own that is: (a) less than 60 feet long; and (b) not being used to carry persons or property for a charge. o NSF Risk Management Division z REVIEWED & APPROVED BY.- -��" Risk Management Analyst CG 89 47 (Ed. 11/14) (Page 2 of 12) * S1 * 03/04/2021 * GLP-4293348-06-02 GREAT AMERICAN ASSURANCE CO 378559 C. Bodily Injury - Mental Injury, Mental Anguish, Humiliation or Shock Under SECTION V - DEFINITIONS, Definition 3. is replaced by the following: 3. "Bodily Injury" means physical injury, sickness, or disease, including death of a person. "Bodily Injury" also means mental injury, mental anguish, humiliation, or shock if directly resulting from physical injury, sickness, or disease to that person. D. Medical Payments If Coverage C - Medical Payments is not otherwise excluded, the Medical Payments provided by this Policy are amended as follows: The Medical Expense Limit in paragraph 7. of SECTION III - LIMITS OF INSURANCE is replaced by the following Medical expense Limit: The Medical Expense Limit provided by this Policy shall be the greater of: a. $20,000; or b. the amount shown in the Declarations for Medical Expense Limit. This provision 7. is subject to all the terms of SECTION III - LIMITS OF INSURANCE. E. Damage to Premises Rented to You If Damage to Premises Rented to You is not otherwise excluded from this Coverage Part: 1. Under paragraph 2. Exclusions of SECTION I - COVERAGE A - Bodily Injury and Property Damage Liability: 3. The last paragraph of paragraph 2. Exclusions is deleted in its entirety and replaced by the following: Exclusions c. through n. do not apply to damage by fire, lightning, explosion, smoke, leakage from an automatic fire protection system or water to premises while rented to you or temporarily occupied by you with permission of the owner. A separate Limit of Insurance applies to this coverage as described in SECTION III - LIMITS OF INSURANCE. However, this insurance does not apply to damage to premises while rented to you, or temporarily occupied by you with the permission of the owner, caused by: i. rupture, bursting, or operation of pressure relief devices; ii. rupture or bursting due to expansion or swelling of the contents of any building or structure, caused by or resulting from water; iii. explosion of steam boilers, steam pipes, steam engines, or steam turbines; or iv. flood. o NSF Risk Management Division z REVIEWED & APPROVED BY.- -��" Risk Management Analyst CG 89 47 (Ed. 11/14) (Page 3 of 12) * S1 * 03/04/2021 * GLP-4293348-06-02 GREAT AMERICAN ASSURANCE CO 378559 2. Paragraph 6. Under SECTION III - LIMITS OF INSURANCE is deleted in its entirety and replaced with the following: 6. Subject to paragraph 5. above, the most we will pay under Coverage A for damages because of "property damage" to any one premises, while rented to you, or in the case of damage caused by fire, lightning, explosion, smoke, leakage from automatic fire protection system or water while rented to you or temporarily occupied by you with the permission of the owner, for all such damage caused by fire, lightning, explosion, smoke, leakage from automatic fire protection systems or water proximately caused by the same event, whether such damage results from fire, lightning, explosion, smoke, leakage from automatic fire protection systems or water or any combination of the six, is the higher of $1,000,000 or the amount shown in the Declarations for the Damage to Premises Rented to You Limit. 3. Under SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS, Subsection 4. Other Insurance, paragraph b. Excess Insurance where the words "Fire insurance" appear they are changed to "insurance for fire, lightning, explosion, smoke, leakage from an automatic fire protection system or water" 4. As regards coverage provided by this provision I. Damage to Premises Rented to You - paragraph 9.a. of Definitions is replaced with the following: 9.a. a contract for a lease of premises. However, that portion of the contract for a lease of premises that indemnifies any person or organization for damage by fire, lightning, explosion, smoke, leakage from automatic fire protection systems or water to premises while rented to you or temporarily occupied by you with the permission of the owner is not an "insured contract"; F. Supplementary Payments 1. In the Supplementary Payments - Coverages A and B provision, paragraph 1.b. is replaced with: 4. Up to $3,000 for 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. 2. Paragraph 1.d. is replaced by the following: d. All reasonable expenses incurred by the Insured at our request to assist us in the investigation or defense of the claim or "suit," including actual loss of earnings up to $1,000 a day because of time off work. G. Newly Formed or Acquired Organizations Paragraph 3. of SECTION II - WHO IS AN INSURED is replaced by the following: 3. Any organization you newly acquire or form and over which you maintain ownership or majority interest, will qualify as a named insured if there is no other similar insurance available to that organization However: a. coverage under this provision is afforded only until the expiration of the policy period in which the entity was acquired or formed by you; b. coverage A does not apply to "bodily injury" or "property damage" that occurred before you acquired or formed the organization; and o NSF Risk Management Division z REVIEWED & APPROVED BY.- -��" Risk Management Analyst CG 89 47 (Ed. 11/14) (Page 4 of 12) * S1 * 03/04/2021 * GLP-4293348-06-02 GREAT AMERICAN ASSURANCE CO 378559 c. coverage B does not apply to "personal and advertising injury" arising out of an offense committed before you acquired or formed the organization. d. records and descriptions of operations must be maintained by the first Named Insured. No person or organization is an insured with respect to the conduct of any current or past partnership, joint venture or limited liability company that is not shown as a named insured in the Declarations or qualifies as an insured under this provision. H. Unintentional Failure to Disclose Hazards Under SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS, the following is added to Condition 6. Representations: Failure of the Insured to disclose all hazards existing as of the inception date of this Policy shall not prejudice the insurance with respect to the coverage afforded by this Policy, provided such failure or omission is not intentional on the part of the Insured. I. Knowledge of Occurrence, Claim or Suit Under SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS, the following is added to Condition 2. Duties in the Event of Occurrence, Offense, Claim or Suit: Knowledge of any occurrence, claim, or suit by any agent, servant or employee of the Named Insured does not in itself constitute knowledge by the Insured unless notice of such occurrence, claim or suit shall have been received by: a. you, if you are an individual; b. a partner, if you are a partnership; c. an executive officer or insurance manager, if you are a corporation. J. Property Damage Liability - Elevators 1. Under paragraph 2. Exclusions of SECTION I - COVERAGE A - Bodily Injury and Property Damage Liability, subparagraphs (3), (4) and (6) of exclusion j. Damage to Property do not apply if such "property damage" results from the use of elevators. 2. The following is added to SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS, Condition 4. Other Insurance , paragraph b. Excess Insurance: The insurance afforded by this provision of this endorsement is excess over any property insurance, whether primary, excess, contingent or on any other basis. K. Property Damage Liability - Borrowed Equipment 1. Under paragraph 2. Exclusions of SECTION I - COVERAGE A - BODILY INJURY AND PROPERTY DAMAGE LIABILITY, subparagraph (4) of exclusion j. Damage to Property does not apply to "property damage" to borrowed equipment while not being used to perform operations at a job site. 2. The following is added to SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS, Condition 4. Other Insurance , paragraph b. Excess Insurance: The insurance afforded by this provision of this endorsement is insurance, whether primary, excess, contingent or on any other basis. excess over any property o NSF Risk Management Division z REVIEWED & APPROVED BY.- -��" Risk Management Analyst CG 89 47 (Ed. 11/14) (Page 5 of 12) * S1 * 03/04/2021 * GLP-4293348-06-02 GREAT AMERICAN ASSURANCE CO 378559 L. Liberalization Clause If we revise this Allied Health General Liability Broadening Endorsement to provide more coverage without additional premium charge, your policy will automatically provide the coverage as of the date the revision is effective in your state. M. Amendment of Pollution Exclusion (Premises) 1. The following is added to paragraph (1)(a) of Exclusion f. of SECTION I - COVERAGE A - Bodily Injury and Property Damage Liability: (iv) "Bodily injury" or "property damage" arising out of the actual discharge, dispersal, seepage, migration, release or escape of "pollutants." As used in this endorsement, the actual discharge, dispersal, seepage, migration, release or escape of pollutants must: (aa) commence on a clearly identifiable day during the policy period; and (bb) end, in its entirety, within seventy-two (72) hours of the commencement of the discharge, dispersal, seepage, migration, release or escape of "pollutants"; and (cc) be discovered and reported to us within fifteen (15) days of the clearly identifiable day that the discharge, dispersal, seepage, migration, release or escape of "pollutants" commences; and (dd) be neither expected nor intended from the standpoint of any insured; and (ee) be unrelated to any previous discharge, dispersal, seepage, migration, release or escape; and (ff) not originate at or from a storage tank or other container, duct or piping which: a. is below the surface of the ground or water; or b. at any time has been buried under the surface of the ground or water and then is subsequently exposed. 2. For the purposes of this coverage, the following is added to the definition of "property damage" of SECTION V - DEFINITIONS and applies only as respects this coverage: Land or water, whether below ground level or not, is not tangible property. 3. Coverage provided hereunder does not apply to any discharge, dispersal, seepage, migration, release or escape that is merely threatened or alleged rather than shown to have actually occurred. N. Limited Property Damage to Property of Others The following is added under SECTION I - SUPPLEMENTARY PAYMENTS - COVERAGES A and B: 4. We will pay up to $5,000 for loss to personal property of others while in the temporary care, custody or control of an insured caused by any person participating in your organized activities. For the purpose of this supplementary payment, loss shall mean damage or destruction but does not include mysterious disappearance or loss of use. In the event of a theft, a police report must be filed. This supplementary payment does not apply if: o NSF Risk Management Division z REVIEWED & APPROVED BY.- -��" Risk Management Analyst CG 89 47 (Ed. 11/14) (Page 6 of 12) * S1 * 03/04/2021 * GLP-4293348-06-02 GREAT AMERICAN ASSURANCE CO 378559 a. coverage is otherwise provided by the Property Coverage part (if any) of this Policy; or b. the loss is covered by any other insurance you have or by any insurance of such person who causes such loss. These payments will not reduce the Limits of Insurance. O. Additional Insured - Manager or Lessor of Premises 1. SECTION II - WHO IS AN INSURED is amended to include as an additional insured any person or organization from whom you lease or rent property and which requires you to add such person or organization as an additional insured on this Policy under: (a) a written contract; or (b) an oral agreement or contract where a Certificate of Insurance showing that person or organization as an additional insured has been issued; but the written or oral contract or agreement must be an "insured contract," and, (i) currently in effect or become effective during the term of this Policy; and (ii) entered into prior to the "bodily injury," "property damage," "personal and advertising injury." 2. With respect to the insurance afforded to the Additional Insured identified in paragraph 1 above, the following additional provisions apply: (a) This insurance applies only with respect to the liability arising out of the ownership, maintenance or use of that part of the premises leased to you. (b) The Limits of Insurance applicable to the Additional Insured are the lesser of those specified in the written contract or agreement or in the Declarations for this Policy and subject to all the terms, conditions and exclusions for this Policy. The Limits of Insurance applicable to the Additional Insured are inclusive of and not in addition to the Limits of Insurance shown in the Declarations. (c) In no event shall the coverages or Limits of Insurance in this Coverage Form be increased by such contract. (d) Coverage provided herein is excess over any other valid and collectible insurance available to the Additional Insured whether the other insurance is primary, excess, contingent or on any other basis unless a written contractual arrangement specifically requires this insurance to be primary. (e) This insurance applies only to the extent permitted by law. 3. This insurance does not apply to: (a) Any "occurrence" or offense which takes place after you cease to be a tenant in that premises. (b) Structural alterations, new construction or demolition operations performed by or on behalf of the Additional Insured. o NSF Risk Management Division z REVIEWED & APPROVED BY.- -��" Risk Management Analyst CG 89 47 (Ed. 11/14) (Page 7 of 12) * S1 * 03/04/2021 * GLP-4293348-06-02 GREAT AMERICAN ASSURANCE CO 378559 P. Additional Insured - Funding Sources 1. SECTION II - WHO IS AN INSURED is amended to include as an additional insured any Funding Source which requires you in a written contract to name the Funding Source as an additional insured but only with respect to liability arising out of: a. your premises; or b. "your work" for such additional insured; or c. acts or omissions of such additional insured in connection with the general supervision of "your work" and only to the extent set forth as follows: a. The Limits of Insurance applicable to the Additional Insured are the lesser of those specified in the written contract or agreement or in the Declarations for this Policy and subject to all the terms, conditions and exclusions for this Policy. The Limits of Insurance applicable to the Additional Insured are inclusive of and not in addition to the Limits of Insurance shown in the Declarations. b. The insurance afforded to the Additional Insured only applies to the extent permitted by law c. If coverage provided to the Additional Insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. d. In no event shall the coverages or Limits of Insurance in this Coverage Form be increased by such contract. Q. Additional Insureds - By Contract 1. SECTION II - WHO IS AN INSURED is amended to include as an insured any person or organization whom you have agreed to add as an additional insured in a written contract, written agreement or permit. Such person or organization is an additional insured but only with respect to liability for "bodily injury," "property damage" or "personal and advertising injury" arising out of: a. your acts or omissions, or the acts or omissions of those acting on your behalf, in the performance of your ongoing operations for the Additional Insured that are subject of the written contract or written agreement provided that the "bodily injury" or "property damage" occurs, or the "personal and advertising injury" is committed, subsequent to the signing of such written contract or written agreement; or b. the maintenance, operation or use by you of equipment rented or leased to you by such person or organization; or c. the Additional Insureds financial control of you; or d. operations performed by you or on your behalf for which the state or political subdivision has issued a permit o NSF Risk Management Division z REVIEWED & APPROVED BY.- -��" Risk Management Analyst CG 89 47 (Ed. 11/14) (Page 8 of 12) * S1 * 03/04/2021 * GLP-4293348-06-02 GREAT AMERICAN ASSURANCE CO 378559 However: 1. the insurance afforded to such additional insured only applies to the extent permitted by law; and 2. if coverage provided to the Additional Insured is required by contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide such additional insured. With respect to paragraph 1.a. above, a person's or organization's status as an additional insured under this endorsement ends when: (1) all work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed for or on behalf of the Additional Insured(s) at the location of the covered operations has been completed; or (2) that portion of "you work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. With respect to paragraph 1.b. above, this insurance does not apply to any "occurrence" which takes place after the equipment rental or lease agreement has expired or you have returned such equipment to the lessor. The insurance provided by this endorsement applies only if the written contract or written agreement is signed prior to the "bodily injury" or "property damage." We have no duty to defend an additional insured under this endorsement until we receive written notice from the Additional Insured of a "suit" as required in paragraph b. of Condition 2. Duties in the Event of Occurrence, Offense, Claim or Suit under SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITION. 2. With respect to the insurance provided by this endorsement, the following are added to paragraph 2. Exclusions under SECTION I - COVERAGE A - Bodily Injury and Property Damage Liability: This insurance does not apply to: a. "Bodily injury" or "property damage" that occurs prior to your commencing operations at the location where such "bodily injury" or "property damage" occurs. b. "Bodily injury," "property damage" or "personal and advertising injury" arising out of the rendering of, or failure to render, any professional architectural, engineering or surveying services, including: (1) the preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; or (2) supervisory, inspection, architectural or engineering activities. This exclusion applies even if the claims against any insured allege negligence or other wrongdoing in the supervision, hiring, employment, training or monitoring of others by that o NSF Risk Management Division z REVIEWED & APPROVED BY.- -��" Risk Management Analyst CG 89 47 (Ed. 11/14) (Page 9 of 12) * S1 * 03/04/2021 * GLP-4293348-06-02 GREAT AMERICAN ASSURANCE CO 378559 Insured, if the "occurrence" which caused the "bodily injury" or "property damage," or the offense which caused the "personal or advertising injury," involved the rendering of, or failure to render, any professional architectural, engineering or surveying services. c. "Bodily injury" or "property damage" occurring after: (1) all work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed for or on behalf of the Additional Insured(s) at the location of the covered operations has been completed; or (2) that portion of "you work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. d. Any person or organization specifically designated as an additional insured for ongoing operations by a separate additional insured endorsement issued by us and made part of this Policy. 3. With respect to the insurance afforded to these additional insureds, the following is added to SECTION III - LIMITS OF INSURANCE: If coverage provided to the Additional Insured is required by a contract or agreement, the most we will pay on behalf of the Additional Insured is the amount of insurance: a. required by the contract or agreement; or b. available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. R. Primary and Non -Contributory Additional Insured Extension This provision applies to any person or organization who qualifies as an additional insured under any form or endorsement under this Policy. Condition 4. Other Insurance of SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS is amended as follows: a. The following is added to paragraph a. Primary Insurance: This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: (1) the Additional Insured is a named insured under such other insurance; and (2) you have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the Additional Insured. b. The following is added to paragraph b. Excess Insurance: When a written contract or written agreement, other than a premises lease, facilities rental contract or agreement, an equipment rental or lease contract or agreem o NSF Risk Management Division z REVIEWED & APPROVED BY. - Risk Management Analyst CG 89 47 (Ed. 11/14) (Page 10 of 12) * S1 * 03/04/2021 * GLP-4293348-06-02 GREAT AMERICAN ASSURANCE CO 378559 a state or political subdivision between you and an additional insured does not require this insurance to be primary or primary and non -contributor, this insurance is excess over any other insurance for which the Additional Insured is designated as a named insured. Regardless of the written agreement between you and an additional insured, this insurance is excess over any other insurance whether primary, excess, contingent or on any other basis for which the Additional Insured has been added as an additional insured on other policies. S. Additional Insureds - Protection of Your Limits This provision applies to any person or organization who qualifies as an additional insured under any form or endorsement under this Policy. 1. The following is added to Condition 2. Duties in the Event of Occurrence, Offense, Claim or Suit: An additional insured under this endorsement will as soon as practicable: a. give written notice of an "occurrence" or an offense that may result in a claim or "suit" under this insurance to us; b. tender the defense and indemnity of any claim or "suit" to all insurers whom also have insurance available to the Additional Insured; and c. agree to make available any other insurance which the Additional Insured has for a loss we cover under this Coverage Part. d. we have no duty to defend or indemnify an additional insured under this endorsement until we receive written notice of a "suit" by the Additional Insured. 2. The Limits of Insurance applicable to the Additional Insured are those specified in a written contract or written agreement or the Limits of Insurance stated in the Declarations of this Policy and defined in SECTION III - LIMITS OF INSURANCE of this Policy, whichever are less. These limits are inclusive of and not in addition to the Limits of Insurance available under this Policy. T. Blanket Waiver of Transfer of Rights of Recovery Against Others to Us (Subrogation) Under SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS, the following is added to Condition 8. Transfer of Rights of Recovery Against Others to Us: If required by a written contract or written agreement, we waive any right of recovery we may have against a person or organization because of payment we make for injury or damage arising out of your ongoing operations or "your work" done under a contract for that person or organization and included in the "products -completed operations hazard" provided that the injury or damage occurs subsequent to the execution of the written contract or written agreement. U. Property Damage Extension with Voluntary Payments 1. The following is added to paragraph 1. Insuring Agreement of SECTION I - COVERAGE A - Bodily Injury and Property Damage Liability: At your request we will pay for loss to property of others caused by your business operations for which this Policy provides liability insurance. Such payment will be made without regard to your legal obligation to do so. The "loss" must occur during the policy period and must take place in the "coverage territory." o NSF Risk Management Division z REVIEWED & APPROVED BY.- -��" Risk Management Analyst CG 89 47 (Ed. 11/14) (Page 11 of 12) * S1 * 03/04/2021 * GLP-4293348-06-02 GREAT AMERICAN ASSURANCE CO 378559 2. With respect to the coverage afforded under paragraph 1. above, paragraph 2. Exclusions of SECTION I - COVERAGES A - Bodily Injury and Property Damage Liability is amended as follows: Exclusions j.(3), j.(4), j.(5) and j.(6) are deleted. 3. As respects coverage afforded by this coverage, SECTION III - LIMITS OF INSURANCE is replaced by the following: Regardless of the number of insureds, claims made or "suits" brought or persons or organizations making claims or bring "suits": 1. Subject to 2. Below, the most we will pay for one or more "loss" arising out of any one "occurrence" is $1,000. 2. The aggregate amount we will pay for the sum of all "loss" in an annual period is $5,000. This aggregate amount is part of and not in addition to the General Aggregate Limit described in paragraph 2. of SECTION III - LIMITS OF INSURANCE. V. Who Is an Insured - Fellow Employee Extention - Management Employees 1. The following is added to paragraph 2.a.(1) of SECTION II - WHO IS AN INSURED: Paragraph (a) and (b) above do not apply to "bodily injury" or "personal and advertising injury" caused by an "employee" who is acting in a supervisory capacity for you. Supervisory capacity as used herein means the "employee's" job responsibilities assigned by you, including the direct supervision of other "employee" of yours. However, none of these "employees" are insureds for "bodily injury" or "personal and advertising injury" arising out of their willful conduct, which is defined as the purposeful or willful intent to cause "bodily injury" or "personal and advertising injury," caused in whole or in part by their intoxication by liquor or controlled substances. This coverage is excess over any other valid and collectable insurance available to your "employee." W. Broadened Personal and Advertising Injury 1. Unless "Personal and Advertising Injury" is excluded from this Policy, the following is added to SECTION V - DEFINITIONS Item 14.: h. mental injury, mental anguish, humiliation, or shock, if directly resulting from Items 14.a. through 14.e. o NSF Risk Management Division z REVIEWED & APPROVED BY.- -��" Risk Management Analyst CG 89 47 (Ed. 11/14) (Page 12 of 12) DATE (MWDDNVYV) CERTIFICATE OF LIABILITY INSURANCE 1110W2021 THIS CERTIFICATE 15 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON'THE CERTIFICATE HOLDER. THIS CERTIFI,CATE 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 CERTIFIGATE HIOLDER. IMPORTANT., If the oeTtificale hiolodILr is an ADDITIONAL INSURED, the pollcy(les) must have ADDITIONAL INSURED provisions or be, ondorsed.. If SUBROOATION IS WAIVED, subject to the terms and conditions, of the policy,. certain policies may roquiro an endorsement, A Statement on this cartiheata doas not confer irighte to the certificate holder in fleu of Such endorsernontfs), Tom Saumur Insurance Agency N.AME mbNr' - - — --------------------- T��A 4242 Obispo Ave (W', M49 F"�L ................ . ....... . . ...... ................... E-MAK Lakewood C.A,901712 . . . . . . . . . ........ . ...... .............. . . NAIG1 .. . . . .. . . . ................................................. .IrtiY34afk.E1R.A . . ............ . ........................ Casa Do La Farnifia Inc 1650 E 4th St Santa Ana Ca 92701 ludson Insurance COVERAGES CERTIFICATE NUMBER; REVISION NUMBER: THIS 13 FO ClRIIFY II -Al 11 IE POLICIES Or- INSURANCE LIS7ED BELOIN HAVE SEEK, ISSUED TO THE IN$URET) NAMEh� A130VC [h"OR 11 IE POLICY PERIOD INDiCATED. NOTWITI iSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CQKTRACT Dr () I'FIER I)OCI)MIENT Wll1 I RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DE SORIBF",f) HERON IS :I!LMJIECT TO ALL THE TERMIS. LXCLUMONS AND CONDINONS OFSUCH POIACIES LIMITSSHOWN MAY HAVE BEEN REDUCED BY` PAID 0I.AIM$. . .. . . . ................. . .... .. . . . ... ...... ............................ . ........................ SUBRI POLICY EFF PIOLKV EXP TYPE OF INSURANCE PMIGY NIUMBF;R (MM,DDIYYYYI 14000,,YYVVI LEMITS GENERAL LILIABILITY E6GH 001-JRRINCE 13 .. ... . ......... . ................ 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IMandalury in N11i I 11 duNci nuu- ixule7 'Y D SCRT710N 07, OPERA71ONG tx!hyx E.L, DI.GEA, -�fn �E . . ..... 51,000,000 C qq Empivyer Liability 104.000 Rolonijun Includes-Suxual MiscondLICt Liability p FP-HN-NPP-3783 3411,6f,2021 0,4A&2022 1,000,000 Aggragate pruidirel DESCRIPTION OF OPERAMONS I'LOCATIONS.1 VEHIGLES IACORD 101, Additional Reimarks Schaduln, may lie atlachnd IN imorn n pare Rn roquiroari ertificate Holder Ulsted as Additional Insured CERTIFICATE HOLDER CANCELLATION City of Santa Ana SHOULD ANY OF THE ABON VE DESCRIBED POLICIES CAE GKEIL QLIED BuFORI�- Risk Management Divison THE EXPIRATION DATE THEREOF, NOTME VUrILL, BAE DELIVERED IN 2C Civic Center Plaza 4Th Floor ACCORDANCE WITH THE POLICY PROVISIONS - Santa Ana, Ca 92!701 EDREPRESENTATIVE %&MwaganedDiMsiun 0) 1988-2015 AC�ORD CO� ,7p' REVIEWED &APPRCYVEDBY.- ACORD 25112016103) The ACORD name and logo are registereld marks of ACORD Profluced 'JAIM9 l'offlis 606s Web Software. www,Forir,0osij,eut,i; y 11wrNpru5sive Publml-iing 9 0,2094977 Risk Management Analyst Casn de I WIN tgo (- o i,i i t 1 1650 F, 4,1, St. MW Ana. ( VT 9270 171 1 A67-522tt 508 W Com rn n n " e a k h A ve , F u 11 e no n, t 4 9283 2 LED A o pi vs Ci P u E 1 11) ;55 0 Vi bA N u 8 k d. `pax: 670. 1 os A up& ea, C k 900 10 12 13 10 3.7 7 77 June 24, 2020 Casa de ki kanvili.a 1-C(jUkCS CV0r ' CM1[A0YQm '�Nrbo drivo. ;! Motor vtdkkp tias pi�u'l cil", his or Iter job dmics (whoki Queruty or inngwndyL and every cinyoyee Ywho uidbes Am do la FnallUds- pmvkkd pxihng in Wnuhi onrl'oh Adde Wgurmwe A at I= to n9hmum habdhy mquVal I i y twx lams o f N w, c t n be r 20O7, t h c i i i i ii i i rtu n i Inability is S 15,000 ff) I i N jI Y(d C,' , 11, 1:1 0 f () t I Q. [10'!m I v; 530M9. O A 41 uryidendi for nwre Own one peso, STODO Ar pwpeny dwrlage). The rencivid, &atc or an Qn,byee; awomo,Nk hwwww will N nowd in his or her per�,,ojinel Mo. 111C Qr)1j+:)YCQ wifl be responihlc A swMAhair g . pro (�) f o (' R'C ti ov al I to ('ass de pat 1-""l El'i i I ill a each immal period. AM u) proyWe psof of rawwal by TQ NnewAl dam! will iwit in ilturi,ediate orow vmMs,nds dKis Otal rupke Tc onphiaQ to dKe as momr vehile. Karina, Paimm-Rojas IdarlAng Pmgmm 11hroor Cna I N AmHia, Risk MxmqvnmiDhVWun REVIEWED & APPROVED BY. - Risk Management Analyst