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<br />DATE (MM/DD/YYYY)
<br />CERTIFICATE OF LIABILITY INSURANCE
<br />7/5/2022
<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 />CONTACT
<br />PRODUCER
<br />Yolanda Medina
<br />NAME:
<br />FAX
<br />PHONE
<br />(805)496-6555(805)497-7870
<br />F and I Insurance Services, Inc.
<br />(A/C, No):
<br />(A/C, No, Ext):
<br />E-MAIL
<br />ymedina@fandiinsurance.com
<br />99 Long Ct.
<br />ADDRESS:
<br />Suite 201
<br />INSURER(S)AFFORDINGCOVERAGENAIC#
<br />Thousand OaksCA91360
<br />Philadelphia Indemnity Insurance Company18058
<br />INSURER A :
<br />INSURED
<br />Preferred Employers Insurance10900
<br />INSURER B :
<br />M.T. X-Ray, Inc., DBA: Modern Technology School
<br />Columbia Casualty Company31127
<br />INSURER C :
<br />16560 Harbor Blvd Suite K
<br />INSURER D :
<br />INSURER E :
<br />Fountain ValleyCA92708
<br />INSURER F :
<br />22-23 GL,Auto,XS
<br />COVERAGESCERTIFICATENUMBER:REVISIONNUMBER:
<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 />ADDLSUBR
<br />INSRPOLICY EFFPOLICY EXP
<br />TYPE OF INSURANCELIMITS
<br />POLICY NUMBER
<br />LTR(MM/DD/YYYY)(MM/DD/YYYY)
<br />INSDWVD
<br />COMMERCIAL GENERAL LIABILITY
<br />X 1,000,000
<br />EACHOCCURRENCE$
<br />DAMAGE TO RENTED
<br />100,000
<br />CLAIMS-MADEOCCUR$
<br />AX
<br />PREMISES(Eaoccurrence)
<br />X PHPK243069307/01/202207/01/2023 5,000
<br />MEDEXP(Anyoneperson)$
<br />1,000,000
<br />PERSONAL&ADVINJURY$
<br />2,000,000
<br />GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE$
<br />PRO-
<br />X 2,000,000
<br />POLICYLOCPRODUCTS - COMP/OP AGG$
<br />JECT
<br />$
<br />OTHER:
<br />COMBINED SINGLE LIMIT
<br />AUTOMOBILE LIABILITY$
<br />1,000,000
<br />(Eaaccident)
<br />BODILYINJURY(Perperson)$
<br />ANY AUTO
<br />A
<br />ALLOWNEDSCHEDULED
<br />BODILYINJURY(Peraccident)$
<br />PHPK243069307/01/202207/01/2023
<br />AUTOSAUTOS
<br />NON-OWNEDPROPERTY DAMAGE
<br />$
<br />XX
<br />HIRED AUTOS
<br />(Peraccident)
<br />AUTOS
<br />$
<br />UMBRELLA LIAB
<br />XX
<br />EACHOCCURRENCE$
<br />1,000,000
<br />OCCUR
<br />EXCESS LIAB
<br />CLAIMS-MADEAGGREGATE$
<br />1,000,000
<br />A
<br />X PHUB82042007/01/202207/01/2023
<br />$
<br />10,000
<br />DEDRETENTION$
<br />PEROTH-
<br />WORKERS COMPENSATION
<br />X
<br />STATUTEER
<br />AND EMPLOYERS' LIABILITY
<br />Y / N
<br />ANY PROPRIETOR/PARTNER/EXECUTIVE
<br />E.L.EACHACCIDENT$
<br />1,000,000
<br />N / A
<br />X
<br />OFFICER/MEMBER EXCLUDED?
<br />B WKN147176-1107/01/202207/01/2023
<br />(MandatoryinNH)
<br />E.L. DISEASE - EA EMPLOYEE$
<br />1,000,000
<br />Ifyes,describeunder
<br />E.L. DISEASE - POLICY LIMIT$
<br />1,000,000
<br />DESCRIPTION OF OPERATIONS below
<br />$1MIL/$1MIL each claim/agg
<br />A Employment Practive Liability PHSD171397507/1/202207/1/2023 Deductible $25k
<br />$1MIL/$5MIL occur/agg
<br />C Professional Liability 411936524 (Claims Made Form)07/20/202207/20/2023
<br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be 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 HOLDERCANCELLATION
<br />AGoodson@santa-ana.org
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />City of Santa Ana
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />Risk Management Division
<br />20 Civic Center Plaza
<br />AUTHORIZED REPRESENTATIVE
<br />Santa Ana, CA 92702
<br />Jesse Cox, Jr./VAN
<br />©1988-2014ACORDCORPORATION.Allrightsreserved.
<br />ACORD25(2014/01)TheACORDnameandlogoareregisteredmarksofACORD
<br />INS025 (201401)
<br />
<br />
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