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Digitally signed
<br />A�
<br />6UI UINpu "y^'4%HULTENB G
<br />ACORO' CERTIFICATE OF LIABILITY INSURA ACe ed(2TE(MM/DD/Y11
<br />� ��eved o Dat : Zo�Ihr2�laa2
<br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON T'.1n CERIWAIVRO �Q2. 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 have ADDITIONAL INSURED provisions or be 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 endorsements .
<br />PRODUCER License # OC88587
<br />CDS Insurance Services
<br />2001 E. Financial Way, Suite 200
<br />Glendora, CA 91741
<br />coMEACT Certificate
<br />Department
<br />AIC,"N , E.t : 626 610-9500 FAX
<br />( ) (AIC, No):(626) 610-9299
<br />E'moAIL . certificates@cdsinsurance.com
<br />INSURERS AFFORDING COVERAGE
<br />NAIC e
<br />INSURER A: Travelers Ind Co of CT
<br />25682
<br />INSURED
<br />INSURER a: Travelers Prop Cas Co of America
<br />25674
<br />Shelter Providers of Orange County DBA: HomeAid Orange
<br />County
<br />INSURER C :State Compensation Ins. Fund
<br />35076
<br />17821 17th Street, Suite 120
<br />INSURER D
<br />INSURER E :
<br />Tustin, CA 92780
<br />INSURER F :
<br />COVERAGES CERTIFICATE NUMBER: 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 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 />INSR
<br />TYPE OF INSURANCE
<br />ADDLSUBR INSD
<br />MDPOLICY
<br />NUMBER
<br />POLICY EFF
<br />POLICY EXPLTR MMIDDIYYM
<br />LIMITS
<br />A
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />CLAIMS -MADE �X OCCUR
<br />P-660-506D7877-TCT-21
<br />121112021
<br />121112022
<br />EACH OCCURRENCE
<br />$ 1,000,000
<br />PREMISES DAMAGESOam,cmm
<br />300,000
<br />GEN'L
<br />MED EXP An one rsan
<br />5,000
<br />PERSONAL B ADV INJURY
<br />Excluded
<br />AGGREGATE LIMIT APPLIES PER
<br />POLICY PRO- LOG
<br />OTHER:
<br />GENERAL AGGREGATE
<br />2,000,000
<br />PRODUCTS-COMP/OPAGG
<br />2,000,000
<br />A
<br />AUTOMOBILE
<br />X
<br />LIABILITY
<br />ANY AUTO
<br />OWNED SCHEDULED
<br />AUTOS ONLY AUTOS
<br />AUTO$ ONLY X FUTNOS ONLY
<br />BA-1L302926-21-43-G
<br />12/1/2021
<br />121112022
<br />COMBINED SINGLE LIMIT
<br />Ea cddm
<br />11000,000
<br />BODILY INJURv Per ersan
<br />BODILY INJURY Per accident
<br />BODILY
<br />Pe�acc,7 AMAGE
<br />B
<br />X
<br />UMBRELLA LIAB
<br />EXCESS LIAB
<br />X
<br />OCCUR
<br />CLAIMS -MADE
<br />EX-8J573284-21-43
<br />121112021
<br />121112022
<br />EACH OCCURRENCE
<br />$ 5,000,000
<br />AGGREGATE
<br />$ 5,000,000
<br />DEO i X I RETENTIONS 0
<br />C
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY YIN
<br />ANY PROPRIETORPARTNEREXECUTIVE
<br />�QppFICER/MEMBER EXCLUDED? Y
<br />(raantlatory in NH)
<br />If yes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />NIA
<br />9147184-21
<br />1111/2021
<br />111112022
<br />X PER OTH-
<br />E
<br />E.L. EACH ACCIDENT
<br />$ 1,000,000
<br />E.L DISEASE - EA EMPLOYE
<br />1,000,000
<br />E.L.DISEASE - POLICY LIMB
<br />1,000,000
<br />DESCRIPTION OF OPERATIONS I LOCATIONS VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required)
<br />City of Santa Ana, its officers, employees, agents, volunteers & representatives are named as Additional Insured on the General Liability with respects to the
<br />operations of the named insured per the attached endorsement form CG D411 04 08. Insurance is primary and non-contributory per attached policy form CG
<br />T1 00 02 19.
<br />City of Santa Ana
<br />Risk Management Division
<br />20 Civic Center Plaza, Aft Floor
<br />Santa Ana, CA 92701
<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 REPClk RESENTATIVE
<br />I.Q-L�_
<br />ACORD 25 (2016103) ©1988.2015 ACORD
<br />The ACORD name and logo are registered marks of ACORD
<br />Risk Management
<br />REVIEWED 6 APPROVED BY:
<br />�'.
<br />®
<br />Risk Management Spedalist
<br />
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