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JCII I Id ILI Id IVI. uignany signea Dy,amamna ivi. <br />I a,.,h,.rr <br />_--1 Lambert Date: 2022.03.16 09:20:35 -07'00' BENS&PR-01 <br />RT N <br />DAT128/2D/YYYY) <br />2/26/zozz <br />,�`oRo CERTIFICATE OF LIABILITY INSURANCE <br />THIS CERTIFICATE IS ISSUED AS A 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 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 # OM10410 <br />Armstrong/Robitaille/Riegle Business and Insurance Solutions <br />1500 Quail St, Suite #100 <br />Newport Beach, CA 92660 <br />CONTACT <br />NAME: <br />PHONE FAX <br />(949) 381-7700 ruc, No :(949 861-9429 <br />WAVE . arrinfo@aleragroup.com <br />INSURER(SI AFFORDING COVERAGE <br />NAIC # <br />INSURERA: Great American Insurance Co. <br />16691 <br />INSURED <br />INSURER B: Insurance Co Of the West <br />27847 <br />INSURER C <br />Benevolent & Protective Order of Elks #794 <br />INSURER 0: <br />1751 S. Lyon St <br />Santa Ana, CA 92705 <br />INSURER E <br />INSURER F : <br />COVERAGES CERTIFICATE NUMBER: REVISION NUMRF_R- <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 />INSR <br />TYPE OF INSURANCE <br />ADDL <br />INSD <br />SUBR <br />MD <br />POLICY NUMBER <br />POLICY EFF <br />POLICY MP <br />LIMITS <br />A <br />X <br />COMMERCIAL GENERAL LIABILITY <br />CLAIMS -MADE OCCUR <br />X <br />PAC395275100 <br />5129/2021 <br />5/29/2022 <br />EACH OCCURRENCE <br />$ 1,000,000 <br />DAMAGE <br />TO RENTPREMISES (Es IED memiel <br />$ 1,000,000 <br />10,000 <br />MED EXP (Any one enum <br />PERSONAL&ADV INJURYk$2,000,000 <br />GEN'L <br />X <br />AGGREGATE LIMIT APPLIES PER: <br />POLICY❑ PROLOC <br />GENERALAGGREGATE <br />PRODUCTS-COMP/OP AGGOTHERA <br />AUTOMOBILE <br />LIABILITY <br />ANY AUTO <br />OWNED SCHEDULED <br />AUTOS ONLY AUTOS <br />AUTOS ONLY X AUTOS ONLY <br />PAC395275100 <br />5129/2021 <br />5/2912022 <br />EOMBINED SINGLE LIMIT otcklimll <br />BODILY INJURY Per erson <br />BODILY INJURY Per accident <br />X <br />Perac (cant AMAGE <br />$ <br />A <br />X <br />UMBRELLALIAB <br />EXCESS LIAB <br />X <br />OCCUR <br />CLAIMS -MADE <br />UMB395275200 <br />5/29/2021 <br />5/29/2022 <br />EACH OCCURRENCE <br />$ 1,000,000 <br />AGGREGATE <br />$ 1,000,000 <br />DEO I X I RETENTION$ 10,000 <br />B <br />WORKERS COMPENSATION <br />AND EMPLOYERS' LIABILITY YIN <br />ANY PROPRIETOWPARTNER/EXECUTNE <br />WE.L.FICER/MEMBER EXCLUDED? <br />(Mandatory in NH) <br />IF yes, describe under <br />DESCRIPTION OF OPERATIONS below <br />NIA <br />WSD506302200 <br />12/5/2021 <br />12I5/2022 <br />X PER OTH- <br />UIEER <br />EACH ACCIDENT <br />1,000,g0g <br />$ <br />E.L. DISEASE - EA EMPLOYE <br />$ 1,000,000 <br />E.L. DISEASE - POLICY LIMIT <br />1,000,000 <br />A <br />A <br />Abuse & Molestation <br />Abuse & Molestation <br />PAC395275100 <br />PAC395275100 <br />5129/2021 <br />5129/2021 <br />5/29/2022 <br />5/29/2022 <br />Each Abuse Limit <br />Aggregate Limit <br />1,000,000 <br />2,000,000 <br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) <br />City of Santa Ana is included as Additional Insured as respects General Liability per the attached forms. <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />Cityof Santa Ana THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />20 Civic Center Plaza <br />Santa Ana, CA 92701 <br />AUTHORIZED REPRESENTATIVE <br />RNLMw�1IadDlsldmL <br />lL y t: Y REmEwEC&APPRovEDBY, <br />ACORD 25 (2016103) 01988-2015 ACORD C <br />The ACORD name and logo are registered marks of ACORD Risk Management Supervisor <br />