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DNIlaOPNeed by hanclno n. <br />Francine R. Villareal''•vigaree <br />Date! 1011M.011e53a1 Web' <br />13UILIND-03 KSHULTENBURG <br />F'1114. `'' CERTIFICATE OF LIABILITY INSURANCE <br />DAT2131202YYYY) <br />213/2021 <br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYAND 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(ft AUTHORIZED <br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER, <br />IMPORTANT: If the certificate holder Is an ADDITIONAL INSUREID, the poHoy(ies) must have ADDITIONAL INSURED provisions or be endorsed. <br />If SUBROGATION IB WAIVEb, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement <br />on <br />this certificate does not confer rights to the certificate holder In lieu of Suoh endorsements). <br />PRODUCER License#OC88587 �Acr Kimberly Shultenburg <br />COS Insurance Services PHONE p % <br />2001 E. Financial Way, Suite 200 Alc, No, eat. 626 $10.9516 <br />Glendora, CA 91741 fAMk...kimbPrlys@cdsinsurance.com <br />INSURER(S)AFFORDINO COVERAGE NAI 0 <br />sURM A r Travelers Ind Co of CT 25682 <br />INSURED <br />INSURER9:Trayelers Prop Cas Co of America <br />25674 <br />Shelter Providers of Orange County DBA: HomeAld Orange <br />County <br />INSURE :State Compensation Ins. Fund <br />35076 <br />17192 Murphy Ave.,#14445 <br />INSURERS: <br />Irvine, CA 02623 <br />INSURER E : <br />INSURER F: <br />--__ __..... ._..._. .sue..• __ MOVIRIVn RUNR9CK' <br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD <br />INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS <br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, <br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br />ILT.NSR <br />TYPEOFINSURANCE <br />ADDL <br />o <br />BUSH <br />Me <br />POLICYNUMSER <br />POLICY <br />EFF <br />POLICY E%P <br />121112021 <br />LIMITS <br />A <br />_ <br />X <br />I COMMERCIAL GENERAL LIABILITY <br />CLAIMS -MADE occuR <br />--- <br />-860.50607877-TCT•20 <br />1211/2020 <br />EACH OCCURRENCE <br />$ 11000,000 <br />MED EXP(Anyone passund <br />01000 <br />5,000 <br />GEN'LAGOREGATE <br />X <br />PERSONAL&ADVINJURY <br />Excluded <br />LIMIT AP UES PER: <br />POLICY ❑ jECT LOU <br />OTHER: <br />G NERALAGGREG TE <br />21000,000 <br />P OQUGTS-COMPlOP G <br />2,000,000 <br />A <br />AUTOMOBILE <br />X <br />LIABILITY <br />ANY AUTO <br />OWNED SCFFIEDULED <br />AILTEO$ONLY ApUt1L08W <br />AUTOS ONLY X AUTUMMEY <br />BA-1L302926.20-14-0 <br />12/112020 <br />12/112021 <br />OM DINED SINGLELIMIT <br />Ea aoeld <br />$ 1,000,000 <br />BODILY INJURY (par erwn <br />�_ <br />RO�DILYRIryNJURYPerccldent <br />PeOflpaclrl AMAOE <br />$ <br />B <br />X <br />UMBRELLA UAB <br />E%CE39 L(AB <br />X <br />OCCUR <br />CLAIMS -MADE <br />EX•BJ573284.20.43 <br />12/112020 <br />121112021 <br />EACH OCCURRENCE <br />6,000,000 <br />A REGA7E <br />5,000,000 <br />DIED I X I RETENTI(N$ D <br />C <br />We rERSCOMPE�ISATION <br />AND EMPLOYRRS' (ABILITY Y <br />AppNYCCPRRROPRIETO�W�PARTNEFWNECUTIVC <br />`ManUelo/ty In NH) EXCLUDES? Y <br />IOESG Or'1ION OFOPERATION3 1 - <br />NIA <br />9147184.20 <br />111112020 <br />111112021 <br />X gTgT OTH" <br />E.L EACH ACCIDENT <br />1,060.000 <br />CL. . DISEASE -EAEMPLOYE <br />$ 1,000,000 <br />E.L. DISEASE-POL POLICY rf <br />1,000,000 <br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (A CORD W 1, Additional Remarks Schedule, may be attached If mare space Isrequired) <br />City of Santa Ana, Its officers, employees, agents, VOlunteers & representatives Oro named as Additional Insured on the General Liability with respects to the <br />operations of the named Insrued per the aftached endorsement form CG D4 1104 08. Insurance is primary and non-contributory per attached policy form CG <br />T1 00 02 19. <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />City of Santa Ana THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />Risk Management Divislon ACCORDANCE WITH THE POLICY PROVISIONS, <br />20 Civic Center Plaza, 4th Floor — <br />Santa Ana, CA 92701 AUTHORIZED REPRESENTATIVE <br />�,Qp � �(g RhkMsnagxmenfDM9m <br />1-A A.kf.+J.. l(J .1/.%1t. - REVIC-WED&APPROVEDBY: <br />ACORD 26 (2016J03) 01988-2015 ACORD C 1 gA1 <br />The ACORD name and logo are registered marks of ACORD Risk Management Analyst <br />