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Tort Digitally signed by <br />Terl Plerson <br />Pierson `' bate: 2021.Uz21 <br />- 15:54:20-0700- <br />`+� CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDONYYY) <br />4a - 07/02/2021 <br />THIS CERTIFICATE IS ISSUED ASA 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 CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED <br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. <br />IMPORTANT. If the certificate holder er Is an A 61TIONAL INSURED, the policy(les) must have AMITIONAL IN URED provisions or We 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 endorsemenl(s). <br />PRODUCER - AMle A DaJohu <br />Carriage Trade Insurance Agency, me. HONE -(516) 358 5600 (516) 356 5656 <br />kell -_...o.Not ,„_... <br />99 Tulip Avenue ADeJohn�CarriageTmdelpsprence.com <br />, <br />ADDRESS. , <br />SLIIC 494 NSnRER191 AFFORBING COVFRAC.F <br />Floral Park NY 11001 INSURER A: Vdesco Insurance Co. "- -- 25011- <br />- INSURERS: <br />INSURED <br />Lutheran Social Services of Southern California INSURER C <br />24'/EAmerige Ave, Fullerton, CA 92832 INSGRERD <br />INSURERE. <br />Fullerton CA 92832����-���-�� <br />NSURE <br />COVERAGES r:FRTIFIr:ATF NIIMRFR• CL217221303 ennornu'aneaeee. <br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED SELOWHAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD --- -- " <br />INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS <br />CERTIFICATE MAYBE 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 />LTR <br />TYPE OF INSURANCE <br />III <br />me <br />POLICY NUMBER <br />MM/DOA'VYY <br />MMIW <br />LIMITS.,. <br />COMMERCIAL GENERAL LIABILITY <br />- <br />CLAIMS -MADE ® OCCUR <br />EACH OCCURRENCE <br />-- <br />$ 1,000,000ODD <br />PRI�11¢ES(Ea%Mren{M <br />y- 100 00 <br />S <br />MED EXP LAnYone Person? .._ <br />§ 5000 <br />_.. .. -. <br />A <br />Y <br />VMP108082501 <br />0701/2021 <br />tl710112022 <br />...W <br />PERSONALA NOV INJURY .. ..$ <br />....:.�m�_ <br />7000000 <br />1LA(s1I,1y1fi0rATff <br />LIMITAPPLIES PER: <br />OUCTpi u LOC <br />GENERALAGGREGATE <br />$ 3000000 <br />PRODUCTS-COMP(OPAGG <br />$ 30000OD <br />THE, <br />Employee Reflects <br />$ 1,000,000 <br />AUTOMOBILE <br />LIABILITY <br />ANYAUTO <br />--- <br />COMBINED SIN MIT <br />$ 1000,000- <br />>(' <br />BODILY INJURY (Par person) <br />$ <br />A <br />OWNED SCHEDULED <br />AUTOS ONLY AUTOS <br />HIRED NON OWNED <br />AUTOS ONLY AUTOSONLY <br />WPPI66062501 <br />07/01/2021 <br />07101/2022 <br />BpDILV INJURY IPar accldonq <br />pm alxltlonl <br />$ <br />_ <br />Medical Expense <br />s 5,000 <br />X <br />UMBRELLA LIAR <br />OCCUR <br />^� <br />EAGH OOOURRENOE <br />$ 3000,000 <br />_'. <br />AGGREGATE <br />$ 31000,000 <br />A <br />Ex0E55 LIAR <br />CLAIMS -MADE <br />WUMIB6635201 <br />07/0112021 <br />0710112022 <br />DEp X RETENTION S 10,000 <br />m <br />$ <br />WORKERS COMPENSATIONmH- <br />AND EMPLOYERS' LIABILITY YIN <br />ANY PROPRIETORIPAR rRERIEXFCUTIVE <br />OFFICERIMEMBER EXCLUDED? <br />(Mandatory In NH) <br />B yse,descdbnunder <br />DESCRIPTION OF OPERATIONS belaxT.. <br />NIA <br />TATUTE <br />E.L. EAOHACGIDENT <br />$ <br />EJ-AI.EASE-FA.EMPLOYE6. <br />$..... <br />E.L.OISEASE-POLICY UMIT <br />$�_ <br />DESCRIPTION OF OPERATIONS I LOCATIONS) VEHICLES (ACORD 1e1, Additional Remarks Schedule, may be anauhed if more space is required) <br />City of Santa Ana, officers, agents, employees, and volunteers are induced as Additional Insureds as with respect to work pertoi'road by the Named Insured <br />as required by written contract, agreement, or memorandum of understanding..Such insurance as is afforded by this policy shall be Primary, and any <br />insurance carried by City shall be excess and noncontributory. Certificate of Insurance shall provide thirty (30) day prior written notice of cancellation, <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 <br />RlekbiacnI"�nAPpRWmor©188B-2016 ACORD fYACORD <br />CA 92702 6:7 <br />26 (2016103) <br />The ACORD name and logo are registered marks ofACORD ,rentoe;wlade <br />