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AI 'jr-%"1-SW <br />Francine R. Digitally slgned by Francine R. <br />R. Villareal <br />Villareal Date: 2021.06.1017:11:17 <br />7''00' <br />� 11i CERTIFICATE OF LIABILITY INSURANCE <br />°"'E`M412021YYY) <br />05(2412U21 <br />THIS CERTIFICATE IS ISSUED ASA MATTER Of INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CENTIPICATEDOES NOT AFFIRMATIVELY OR NEGATIVELY <br />AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE ACONTRACT BETWEEN THE ISSUING INSURER(S), <br />AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLOER, <br />IMPORTANT: IfthecertlRcateholder is an ADDITtONALINSURED,the poltt0 s)muttImmADDITIONAWNSURED provIslons or be endorsed, It SUBROGATION IS WAIVED, sublectto the termsano <br />camiltiens of the policy, certain policies may require an endomelnenN Astatement on thlscertiaaatedoosnot confer rights to the certificate holder In lieu of such endoraoment(s)- <br />PRODUCER <br />CONTACT <br />NAME: Theresa SIme3 <br />Therese Simes(9744576) <br />PHONE <br />FAX <br />17165 Newhope St Ste F <br />(A/C, NO, EXT); 714-966.3000 <br />(A/C, NO): 714-966.3013 <br />E-MAIL <br />ADDRESS: tsitneSCfarmersagenLrom <br />Fountain Valley CA 927U6-4230 <br />INSURER(S) AFFORDING COVERAGE <br />NAIC# <br />INSURED <br />INSURERA: Truck lnauranco Exchange <br />21709 <br />WILLIAMHNUESSEM.D. <br />807 $ TUSTIN ST <br />INSURERS-. Formers Insurance Exchange <br />21652 <br />INSURERSs Mid Century Insurance Company <br />21687 <br />INSURERD; <br />ORANGE CA 92866 <br />BLEMRERE.. T <br />INSURER <br />COVERAGES CERTIFICATE NUMBER; REVISIONNUMBER; <br />THISISTO (TWIT YTHATTHEPOLICIESOF INSURANCE LISTED BELOW HAVE BEEN ISSUEDT07HEINSURED NAMEABOVE FORTHE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY <br />REQUIREMENT, TERM OR CONDITION OFANY CONTRACTOR OTHERDOCUMENTWITH RESPECTTO WHICHTHISCERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE <br />POLICIES DESCRIBEDHEREIN ISSUBJECTTOALLTHETERMS, EXCLUSIONSANO CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br />IL1RR <br />TYPEOFINSURANCE <br />�NSDL <br />SOU <br />POLICYNUMBER <br />POLICY EFF <br />(MM/DD/YWY) <br />POUCYEXP <br />(MM/DD/YYYY) <br />LIMITS <br />COMMERCIALGENERALLIABILITY <br />CLAIMS -MADE OCCUR <br />_ <br />EACHOCCURRENCE <br />$ 200D000 <br />DAMAGETO RENTED <br />S(Ea Occurrence) <br />$ 500.000 <br />MEP EXP(Anyone person) <br />$ 500 <br />PERSONALeADVIN)9RY <br />s 2,009,00 <br />A <br />V <br />N <br />802378275 <br />OW2912021 <br />06/29/2022 <br />ODA AGGREGATELIMHAPPLIESPER: <br />POLICY ❑ PROJECT ❑ WC <br />GENEKALAGGREGATE <br />$ 4,000,000 <br />PRODUCTS -COMP/OPAGG <br />$ 2,000,000 <br />$ <br />OTHER: <br />ODILEUABILITY <br />COMBINEDSINGLE LIMIT <br />(Eanceident) <br />$ 2,000,000 <br />YAUTO <br />ROPILYINJURY(Parperson) <br />$ <br />YEDAUTOS SCHEDULED <br />N <br />602378275 <br />05/29/2021 <br />06129/2022 <br />BODILYINJURY(Peraccldent) <br />$ <br />PROPERTY DAMAGE <br />(Peracdden@ <br />$ <br />£OAUTOS X NON -OWNED <br />LY AUTOS ONLY <br />S <br />BRELLALIAB <br />PANDEMPLOYSRS'LISADILITY <br />OCCUR <br />EACH OCCURRENCE <br />$ <br />AGGREGATE <br />¢ �✓ <br />CEaS LIAR <br />CLAIMS -MADE <br />0 RETENTIRS <br />COMPENSATION <br />LMDILITY <br />PER <br />STATUTE <br />OTHERPLOYERS' <br />OPRIETOR/PARTNER/ Y/N <br />in NH) <br />N/AE.L <br />EACH ACCIDENTIVEOFFICER/MEMBERED7(Mandatory <br />£.L. GISEABE-EA EMPLOYEE <br />E.4' DISEASE •POUCY10AH <br />S <br />escribe underDESCRIPTION OF <br />TIONS below <br />DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES WORD 101, Additional Remarks Schedule, may be attached if more space Is required) <br />87 S TUSTIN ST, ORANGE, CA 02866 <br />Certificate of Insurance shall provide 30 day prior written notice of concellation <br />CERTIFICATEHOLDER CANCELLATION <br />20 CIVIC CENTER PLZ <br />DATE <br />ACORD 25(2016/03) @1988-2015 ACORDC REVIEWED & APPROVED BY: <br />31.1769 11-15 The ACORD name and logo are registered marks <br />Risk Management Analyst <br />