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A/"J'90 r® <br />Francine R. Digitally signed by Francine R. <br />Villareal <br />Villareal Date; 2021.06.1017:11:17 <br />-07'00' <br />CERTIFICATE OF LIABILITY INSURANCE <br />°Aoerz4(20ZI Y"' <br />THISCERTINCATEIS ISSUED AS A MATTER OF INFORMATION ONLYAND CONFERS NO RIGHTSUPONTHECERTIFICATE HOLDER,THISCERnFICATE DOES NOTAFFIRMATIVELYOR NEGATIVELY <br />AMEND, EXTEND ORALTERTHE COVERAGEAFFORDED BYTHE POLICIES BELOW.THISCERTIFICATE OF INSURANCEDOES NOTCONSTITUTEACONTRACT BETWEENTHEISSUING INSURERS), <br />AUTHORIZED REPRESENTATIVEOR PRODUCER, ANDTHECEROFICATEHOLDER. <br />IMPORTANT.IfthteeniBataholderlsan ADDmONALINSURED,th%Polley(las)mosthmeADOn10NAL1NSURVDPnMslonswbeendorsed,lfWBRoW[ON1SWAIVED,subja tothetermsand <br />condilionsofths polity, certain wilcim mayfequiman endorsement Asmlement on thbmrtlBmmdoesnatconh:rfightstothemrUg"teholderin neo ofsuch wdomemmN(s). <br />PRODUCER <br />CONTACT <br />NAME: Theresa Simes <br />Theresa Simes(9744576) <br />PHONE <br />FAX <br />17165 Newhope St SIR F <br />(A/C, NO, EXT): 714-966-3000 <br />(A/C, NO): 714-966-3013 <br />E-MAIL <br />Fountain Valley CA 92708-4230 <br />ADDRESS: tsimes@fannersagent.00m <br />INSURERS) AFFORDING COVERAGE <br />NAICR <br />INSURED <br />INSURERA: Truck Insurance Exchange <br />21709 <br />Insurance Exchange <br />21552 <br />WILLIINSURERS-.Farmers <br />867 S TUSTIN ST M H NUESSE M.D. <br />67 S <br />INSURERC Mid Century Insurance Company <br />21687 <br />INSURE0.O: <br />ORANGE CA 92866 <br />INSURERS: <br />INsURERF: <br />COVERAGES CERTIFICATE NUMBER. REVISIONNUMBER <br />THGISTOCERTIFYTHATTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUEDTOTHE INSURED NAMEABOVEFORTHEPOUCY PERIOD INDICATED. NOTWITHSTANDINGANY <br />REQUIREMENT, TERM OR CONDITION OFANY CONTRACTOR OTHER DOCUMENT WITH RESPECrTO WHICH THISCERTIFICATE MAYBE ISSUED OR MAY PERTAM,THE INSURANCEAFFORDED BYTHE <br />POLICIESDESCRIBED HEREIN ISSUBJECTTOALLTHETERMS, EXCLUSIONSAND CONDITIONSOFSUCH POLICIES. LIMITSSHOWN MAYHAVE BEEN REDUCED BYPMDCW MS. <br />INSR <br />17R <br />TYPEOFINSURANCE <br />ADDTL <br />INSO <br />BUBR <br />WVD <br />Polio NUMBER <br />POLICY EFF <br />(MM/DD/YYYY) <br />POLICY EXP <br />(MM/DD/YYYY) <br />LIMBS <br />A I <br />COMMERCIALGENERALLIABILRY <br />CLAIMS-MADE OCCUR <br />Y <br />N <br />602378275 <br />05/2912021 <br />05/29MO22 <br />EACHOCCURRENCE <br />S 2,000,00 <br />DAMAGETORENTED <br />PREMISES(Ea Occurrence) <br />S <br />500,00 <br />MEDEXP(Anyonaparson) Is <br />600 <br />I <br />PERSONALBADVINJURY <br />S 2,000.00 <br />GEN'L AGGREGATEUMITAPPUESPER: <br />POLICY ❑ PROJECT ❑ LOC <br />OTHER: <br />GENERALAGGREGATE <br />$ 4,000.00( <br />PRODUCTS-COMP/OPAGG <br />S 2,000.00 <br />S <br />A <br />AUTOMCBILEUABIUTY <br />ANYAUTO <br />OOWVEDAUTOS SCHEDULED <br />AUTS <br />HIREDAUTOS X NON -OWNED <br />ONLY AUTOS ONLY <br />N <br />602378275 <br />05/2912021 <br />05/2W022 <br />COMBINEDSINGIEUMIT <br />(Ea accident) <br />$ 2,000,00 <br />BODRYINJURY(Pe parson) <br />$ <br />BODRYINJURY(PerarCdent) <br />$ <br />PROPERTY DAMAGE <br />(Peracck)ant) <br />$ <br />S <br />UMBBELLALIAB <br />EXCESSI <br />OCCUR <br />CWM&MADE <br />EACH OCCURRENCE <br />S <br />AGGREGATE <br />S <br />DIED RETENTIONS <br />S <br />WORRERSCOMPENSATION <br />AND EMPLOYERS' LIABILITY <br />ANY PROPRIETOR/PARTNER/ Y/N <br />EXECUTIVE OFFICER/MEMBER <br />EXCLUDED? (Mandatory in PH) <br />Ifyes, describe under DESCRIPTION OF <br />OPERATIONS belaw <br />N/A <br />PER <br />STATUTE <br />OTHER <br />$ <br />E.L. EACH ACCIDENT <br />S <br />F.L. DISEASE -EA EMPLOYEE <br />E.L DISEASE -P06CY LIMIT <br />S <br />DESCRIPf WN RATIONS/LOCATIONS/VEHICLES(ACORD 101, Additional Remarks Schedule, may be attached If mom space is requlmd) <br />67 S TUSTIN ST, ORANGE, CA 92865 <br />ertigcate of insurance shall provide 30 day prior written notice of cancellation <br />CERTIFICATEHOLDER <br />20 CIVIC CENTER PLZ <br />CANCELLATION <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES <br />DATE THEREOF NOTICE WILL BE DPIIVVERR]EO�I�jJ ADO <br />AUT14ORMO REPRESENTATal ,{)y/7A V7� <br />y.. ACORD 25 (2016/03) ®7988-2015ACORDC �" . �5 REAEWED&APPROVED BY: <br />31-1769 11-15 The ACORD name and logo are registered marks ofACORD �^A^H^^'c �• �` <br />Risk Management Analyst <br />