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mgllally signed by Frandne R. <br />Francine R. Villareal vina,aal <br />Date: 2021 A2.0910:Ra 1 o8oa' <br />BUILIND-03 KSHULTENBURG <br />`A� o CERTIFICATE OF LIABILITY INSURANCE <br />DATE <br />213/2021 <br />21 <br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS <br />CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES <br />BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED <br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. <br />IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. <br />If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on <br />this certificate does not confer rights to the certificate holder in lieu of such endorsements). <br />PRODUCER License#OC88587 <br />CDS Insurance Services <br />2001 E. Financial Way, Suite 200 <br />Glendora, CA 91741 <br />TACT Kimberly Shultenburg <br />PHONEE FAx <br />A/c, No, Eat): (626) 610-9516 AIC, No): <br />VoAIESS: kimberlys@cdsinsurance.com <br />INSURERS AFFORDING COVERAGE <br />NAIC 0 <br />INSURER A: Travelers Ind Co of CT <br />25682 <br />INSURED <br />Shelter Providers of Orange County DBA: HomeAid Orange <br />County <br />INSURER B:Travelers Pro Cas Co of America <br />25674 <br />INSURER c: State Compensation Ins. Fund <br />35076 <br />INSURER D : <br />17192 Murphy Ave., #14445 <br />INSURER E : <br />Irvine, CA 92623 <br />INSURER F: <br />COVERAGES CERTIFICATE NUMBER: REVISION NUMBER• <br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD <br />INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS <br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, <br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br />IL SR <br />TYPE OF INSURANCE <br />ADDLSUBR <br />p <br />we <br />POLICY NUMBER <br />POLICY EFF <br />POLICY EXP <br />LIMITS <br />A <br />X <br />COMMERCIAL GENERAL LIABILITY <br />CLAIMS -MADE OCCUR <br />Y-660-506D7877-TCT-20 <br />12/1/2020 <br />12/112021 <br />EACH OCCURRENCE <br />$ 1,000,000 <br />DAMAGETORENTED <br />E <br />SES a oc <br />300,000 <br />5,000 <br />GEN'L <br />X <br />MED EXP An ane ersan <br />PERSONAL &ADV INJURY <br />Excluded <br />AGGREGATE LIMIT APPLIES PER: <br />POLICY❑YE0 D LOG <br />OTHER: <br />GENERAL AGGREGATE <br />2,000,000 <br />PRODUCTS - COMP/OP AGG <br />21000,000 <br />A <br />AUTOMOBILE <br />JxANY <br />LIABILITY <br />AUTO <br />OWNED SAUTOS CHEDULED <br />OWNS ONLY ICHEDU <br />AUTOS ONLY X AUUTNOOS ONLY <br />BA-11-302926.20-14-13 <br />1211/2020 <br />12/112021 <br />COeBINED SINGLE LIMIT Iden)$ <br />1,000,000 <br />BODILY INJURY Per arson <br />$ <br />BODILY INJURY Per accident <br />$ <br />f a0P.ER ant AMAGE <br />$ <br />B <br />X <br />UMBRELLA LIAB <br />EXCESSLIAB <br />X <br />OCCUR <br />CLAIMS -MADE <br />EX-8J573284.20.43 <br />12/1/2020 <br />121112021 <br />EACH OCCURRENCE <br />$ 5,000,000 <br />AGGREGATE <br />5,000,000 <br />DEC X RETENTION$ D <br />C <br />AND EMPLOYERS' �ER9ELIABILOIP/ YIN <br />A0 FFIPRRORPRIETORIPARTNERIEXECUTIVE <br />`ManEatory In NH)EXCLUOEO'! <br />(DESCRIPTION OF OPERATIONS below <br />NIA <br />9147184.20 <br />11/1/2020 <br />111112021 <br />X STAT OTRH- <br />EL EACH ACCIDENT <br />$ 1,000,000 <br />E.L. DISEASE CA EMPLOYEE <br />$ 1,000,000 <br />E.L. DISEASE -POLICY LIMIT <br />1,000,000 <br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) <br />City of Santa Ana, its officers, employees, agents, volunteers & representatives are named as Additional Insured on the General Liability with respects to the <br />operations of the named insrued per the attached endorsement form CG 04 1104 08. Insurance is primary and non-contributory per attached policy form CG <br />T1 00 02 19. <br />City of Santa Ana <br />Risk Management Division <br />20 Civic Center Plaza, 4th Floor <br />Santa Ana, CA 92701 <br />ACORD 25 (2016103) <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />AUTHORIZED REPRESENTATIVE CA C rJAg <br />©1988-2015 ACORD <br />The ACORD name and logo are registered marks of ACORD <br />�a^s NMMAn9�Elaem VMBIOR <br />i REVIEwm&APPROVEDBY: <br />al' <br />`� fllsk Management Malys[ <br />