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l Digitally signed by Francine R.Villareal
<br />Francine R. Villarea
<br />Date: 2021.07.13 15:38:24 -0T00'
<br />ACORO� CERTIFICATE OF LIABILITY INSURANCE
<br />�ki
<br />DATE (MMIDDIYYYY)
<br />7/7/2021
<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 be endorsed. If SUBROGATION IS WAIVED, subject to
<br />the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
<br />certificate holder in lieu of such endorsement(s).
<br />PRODUCER
<br />CONi NAME: Yolanda Medina
<br />F and I Insurance Services, Inc.
<br />AICNNo 1(805) 496-6555 AAIX Ni (805)497-7970
<br />ADDRESS:ymedi.na@fandi.i.nsurance.com
<br />99 Long Ct .
<br />Suite 201
<br />INSURERS) AFFORDING COVERAGE
<br />NAIC N
<br />INSURERA:Philadelphia Indemnity Insurance Com ar.
<br />18058
<br />Thousand Oaks CA 91360
<br />INSURED
<br />INSURER B: Preferred Employers Insurance
<br />10900
<br />INSURER C: Columbia Casualty Company
<br />31127
<br />M.T. X-Ray, Inc., DBA: Modern Technology School
<br />INSURERD:
<br />16560 Harbor Blvd Suite K
<br />INSURER E
<br />INSURERF:
<br />Fountain Valley CA 92708
<br />COVERAGE5 CERTIFICATE NUMBER:21-21 GL,Auto,XS 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 OFANY 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 />INSR
<br />LTR
<br />TYPE OF INSURANCE
<br />ADOL
<br />INSD
<br />SUBR
<br />WVD
<br />POLICYNUMBER
<br />POLICY IPOLICY
<br />MMIDDIYYW
<br />ILIMITS
<br />MMIDDIYYW
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />EACH OCCURRENCE
<br />$ 1,000,000
<br />A
<br />CLAIMS -MADE FOOCCUR
<br />DAMAGE TO RENTED
<br />PREMISES Ea occurrence
<br />$ 100,000
<br />MED EXP (Any one person)
<br />$ 5,000
<br />X
<br />PHPK2249152
<br />5/17/2021
<br />7/l/2022
<br />PERSONAL & ADV INJURY
<br />$ 1,000,000
<br />GEN'L
<br />AGGREGATE LIMIT APPLIES PER.
<br />GENERAL AGGREGATE
<br />$ 2,000,000
<br />POLICY ❑ PRO ECT ❑ LOC
<br />X
<br />PRODUCTS - COMPfOPAGO
<br />$ 2,000,000
<br />$
<br />OTHER
<br />AUTOMOBILE
<br />LIABILITY
<br />COMBINEDSINGLE LIMIT
<br />Ea accident
<br />$ 1,000,000
<br />BODILY INJURY (Per person)
<br />$
<br />A
<br />ANY AUTO
<br />ALL OWNED SCHEDULED
<br />AUTOS AUTOS
<br />eHPK2249152
<br />5/17/2021
<br />7/1/2022
<br />BODILY INJURY {Per accident}
<br />$
<br />X
<br />PROPERTY DAMAGE
<br />Per accident
<br />$
<br />X NON -OWNED
<br />HI RED AUTOS AUTOS
<br />X
<br />UMBRELLA LIAB
<br />X
<br />OCCUR
<br />EACH OCCURRENCE
<br />$ 1,000,000
<br />AGGREGATE
<br />$ 1,000,000
<br />A
<br />EXCESS LIAB
<br />CLAIMS -MADE
<br />DED I X I RETENTION $ 10,000
<br />$
<br />PHUB759977
<br />5/17/2021
<br />7/l/2022
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY YIN
<br />X PER OTH-
<br />STATUTE ER
<br />B
<br />ANY FRCFRIETORIFARTNERIEXECUTIVE
<br />OFFCERfM EM E ER EX CLU D ED? Y❑
<br />(Mandatory in Ni
<br />NIA
<br />QFKN147176-10
<br />7/l/2021
<br />7/l/2022
<br />EL EACH ACCIDENT
<br />$ 1,000,000
<br />E.L.DISEASE - EA EMPLOYEE
<br />$ 1,000,000
<br />f yes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />EL DISEASE -POLICY LIMIT
<br />$ 1,000,000
<br />A
<br />Employment Practive Liability
<br />PHSD1627952
<br />5/17/2021
<br />7/l/2022
<br />$1MIL!$1MIL each clairrJagg Deductible $25k
<br />C
<br />Professional Liability
<br />411936524 (claims Made Form)
<br />07/20/2020
<br />07/20/2021
<br />$11MIL46MILoccurlagg
<br />DESCRIPTION OF OPERATIONS I LOCATIONS VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required)
<br />The City of Santa Ana, its officers, officials, employees and volunteers are named as Additional Insured
<br />with respects to the General Liability per form #PI-GLD-VS (05/17)
<br />*10 days notice of cancellation applies to non-payment of premium, 30 days all other;
<br />CERTIFICATE HOLDER CANCELLATION
<br />AGoodson@santa-ana.org
<br />City of Santa Ana
<br />Risk Management Division
<br />20 Civic Center Plaza
<br />Santa Ana, CA 92702
<br />ACORD 25 (2014101)
<br />INS025 (201401)
<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
<br />HORaN Risk Manag�:IrtentDiAsian
<br />Jesse Cox, Jr. /VAN z% REVIEWED&APPROVED BY.-
<br />© 1988-2014 ACORD C P1. (/j&441d
<br />The ACORD name and logo are registered marks of ACORD ' Risk Management Analyst
<br />
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