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CERTIFICATE OF LIABILITY INSURANCE DATEVM?A.TlnlYYwq <br />12MA2020 <br />TH15 CERTIFICATE IS ISSUED AS A MATTER Or- INFORMATION ONLY AND CCMNkFER$ N0 RIGHTS UPON THE CERTIFICATE HOLDER- THIS <br />CERTIFICATE DOES NOT A FFIR MATIVELY OR N EGATIVE LY AMEN D, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES <br />BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT 13ETWEEN THE ISSUING INSURER(S), AUTHORIZED <br />REPRESENTATIVE OR PRODUCER, AND THECERTIEMCATE HOLDER. <br />IMPORTANT: if the certificate holder is an ADDITIONAL INSURED, the pollcy{Ios) must have ADDITIONAL INSURED PFGA51on9 or be endorsed, <br />If 8U6ROGATION IS WAIV'EO. subject to the terms and cnnditiom of the policy, certaln policies may r9quir8 art and0rsament- A statement on <br />this certificate does not confar dohis to tho cortificata holder in lied Of such -en dorsernerlt(S). <br />PHOOUCGR <br />CONOdelia Samya <br />Nf%KIE <br />Capital Providers Insurance <br />PHONE 1818} �}1i-091�i FAIT ?318j 675-7015 <br />AD Nol <br />License #OH52316 <br />E4v A L Odelis@CMSGroup-com <br />ADDRESS: <br />207E0 Ventura Blvd-, Ste 305 <br />IrAURER(5) AFF(]RMOR) COVERAGE <br />NALU x <br />'Uccdland Hills CA y1164 <br />INSURERA: ,Falls Lake Rre $ Casualty Company <br />15884 <br />INSURED <br />INSURER B <br />Medina, Guada upe. DBA: Sang Fe Building Malwp.na ce <br />IN9EIRER C : <br />16544 Ralomeno Drive <br />INSURER D <br />' <br />INSURER E : <br />Chino Hills CA @ 17PA <br />INSURER F : <br />COVERAGES CERTIFICATE: NUMBER: 2021 Vic RLVISION NUMBER_ <br />TIIIF3 I ` 70 CERTIFY THAT THE POLI USES OF INSURANCE LISTED BELOVil HAVE SEEN ;SS.LIEU -0 FHE INZA)RED NAMED ABOVE FOR THE POLICY PERIOD <br />IND ICA ED. NOTWITHSTAND ING ANY REQU IREMENT, TERM OIL CON OITION �)F ANY € ONTRAC,7 OTHER DOCUMENT WITH RESPECT TO WH ICH THIS <br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. 7FrE CNSURANINE AFFORDE13 6Y TliF Po,,.,C r.S DESCRIBED HEREIN IS SUBJECT TOALL THE TERF#4, <br />EXCLUSIONS AND CONDITIONS OF SUCH POLI€AES OMITS SHOWN MAY HAVE BEEN REDUC E D BY PAID CLAIMS. <br />- <br />iN! <br />L.TR <br />TYPE OF FNSLIRANCE <br />11,130 <br />y'] <br />.. <br />pOLIGY NLrM13ER <br />POLICY t=F <br />I's1rJl,�l?UiYYYY <br />L.. <br />P Y E%P <br />MM.DrWrYYY <br />LIDAITS <br />COMMERCIAL OEH FRAIL LIABILITY <br />EdUH 01f:Ct1l3REHL,F <br />PREMISES'Ea xCuw.nrrn <br />A <br />r.,Lk,kiS•F.inu= El t7CCIJR <br />MED EXP (Any cvn p.Lr2in1 <br />s <br />PER93NAL S ALN 1NxiRY <br />$ <br />3CNLAGGREGATE LIre1AH's-16'�NEk <br />pt]LICY PRO- <br />❑. Lek: <br />GENERALArCHE(iAIE <br /># <br />PRDSUCTS . CL7llM'(X- +Ura <br />t <br />S <br />CTI IER. <br />A.I-�AMRILE <br />LIABILITY <br />Cca1�11 D sIN&LC LKIIT <br />Ea accrJent <br />t <br />BODLYINAIRYMumscnl <br /># <br />AV'fALrr <br />OWNED SCHEJLLCD <br />AJTCY30HLY AUFCS <br />BOD LY lNJL1RY {Per accdentl <br />L <br />HIRED ND4-Crh'r,G_D <br />A:JPO ONLY AU CS ONLY <br />f RM7n=RTY DANWGE <br />PerociceM', <br /># <br /># <br />UMEtREILLA LIAR <br />()Gr.kIR <br />EAC. H CSCCUNRE 4(:F <br />AGGHECA:IE <br />S <br />E=E95LIAB <br />CI. AIMti-tdAnF <br />OLD I I RE IHN I KINti <br />WORKERS COMPENSAr1DN <br />* PER OI I - <br />A <br />AHi} EMPLOYERS! LIA131Lrr't' Y �w <br />ia`JV FR,!)FR:FT�]R.'PARTNFRT%XF01jT VE <br />{;-FIL:E HiYWMI'IFR FXr'I ,In 77El <br />{Mandarrwy In NHI <br />livyees tlescri7c untlrr <br />UEuCHI?I ION OF '.)FIE RAI 10KIS I;Aa <br />NJA <br />FLA01589100 <br />12!1�,C= <br />12.1 <br />I.TUT=EH <br />. <br />L.L. <br />1,OC(},{Yf]Cr <br />6.1 . JNhASh HA Fr.F4. •DYEE <br />5 1,OCIli,bOfr <br />L.I. JI!iHANI, F131 C.V I IMIT <br />$ 1.000.0.90 <br />L_ <br />I <br />I <br />L <br />I I <br />— <br />DESCRIPTi4N OF OPERATION 5! LOCATIONSJ VEHICLES 000RO 101.Addllianal Remarks Schotluw may beaitarhnd Irmorg gpgee In wuIrm) <br />Job .ocation: <br />20 CIVIC CENTER PLAZA., SAtdTAANA, CAD2701 <br />CITY OF SANTAANA RISK MANACFMF.NT DIVIS60Lwl <br />20 CIVIC CENTER PLA7A <br />4TH FLOOR <br />SANaTA ANA <br />CA 927C• <br />S HL ULD ANY OF THE ABOV E o E$CMEIGD PCILIC IES BE CANC ELLEi BEF412E <br />THE EXPIRATION GATE THEREOF, NOTICE WILL BE DELIVERED IN <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />AUTilOR2CD REFRESEN TATNE <br />_^— Ride Menage nenf Thviei. <br />Y -- — REVIEwED is APPROVED BY: <br />C'r11388-2016ACORD r -701ze 1­1 <br />ACORD 25 (201 Gr031 The,ACORD name and logo are registered marks of AC OR Risk Management 0eri-[ Aide <br />