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, ACORD. CERTIFICATE OF LIABILITY INSURANCE CSR PF I DATE (MMIDDlYYYY) ,-'" SYMCO-1 01/25/05 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OFINFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFCATE Burnette Insurance Agency, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 3447 Lawrenceville Suwanee Rd. ALTER THE COVERAGE AFFORDED BY THE POLCIES BELOW. Suwanee GA 30024-2402 I INSURERS AFFORDING COVERAGE . T NAIC # Phone: 770-339-8888 Fax:770-339-1442 INSUREO'-~-. - A-;;>.L"X) I~I:;'-~ t----~ INSURER A: Zurich U. S. Insurance A- CJODJ- 14'-1 I INSURER B_ Legion Insurance Company S05co GrouPi: Inc. A-;;:<"OD3 -//2- INSURER C I 1 5 Satel11 e Blvd. Suite 5 I INSURER D Suwanee GA 30024 A-,;t-tly!-o9% I INSURER E: COVERAGES THE POLICIES OF iNSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTifiCATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS A NSR TYPE OF INSURANCE GENEr~L L1AtllLlTY !Jel. c cmOMMERCIAL GENERAL LIABILITY in CLAIMS MADE ~ OCCUR Er-.-- I' , GEN'LAGGREGATE LIMIT AP~S PER: X POLICY j~8T" LOC AUTOMOBILE LIABILITY ~~ ANY AUTO H ALL OWNED AUTOS , SCHEDULED AUTOS o HIRED AUTOS ~ NON-OWNED AUTOS POLICY NUMBER I PJl~i~v,.i~r6~E I P8k!feY~:hRlrW LIMITS LTR A 07/31/04 07/31/05 EACH OCCURRENCE , PREMISES (Ea occurence) MED EXP (Anyone person) , PERSONAL & ADV iNJURY I GENERAL AGGREGATE PRODUCTS - COMP~OP AGG $1,000,000 $300,000 $10,000 $ 1,000,000 $2,000,pOO $2,000,000 040972979 040972979 07/31/04 07/31/05 COMBINED SINGLE LIMIT (Eaaccidenl) $1,000,000 , BODILY INJURY $ I (Per person) ! , BODILYINJURY +- ; (Peraccldenl) -~--- ._--- j PROPERTY DAMAGE $ (per accident) 07/31/04 07/31/05 AUTO ONLY - EA ACCIDENT $ EAACC $ AGG $ $1,000,000 AGGREGATE $ 1 000 000 --~~' ,$ EACH OCCURRENCE GARAGE LIABILITY ANY AUTO I NOT APPLICABLE I 040972979 OTHER THAN AUTO ONLY: A EXCESS/UMBRELLA LIABILITY OCCUR r--, CLAIMS MADE h DEDUCTIBLE !xl RETENTION $ 0 I WORKERS COMPENSATION AND EMPLOYERS' LIABILITY B ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below I OTHER I 11/28/04 $ 100,000 EL DISEASE EA EMPLOYEE $ 100 I 0 Q 0 E.L.DISEASE-POLlCYLlMIT; $ 500 I 000 I WC50548357 11/28/05 ER APPROVED AS TO hh"" DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES J EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Certificate holder is listed as additional insured as per contractual obligaticn./Faxed 714-647-5406.SEE REVISED WC INFORMATION. /c}f,..~ S:::- . Laura Still SltCcdy"-' Assistant CilV AllOl'lI,'. CERTIFICATE HOLDER CANCELLATION SANTAAN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATIO DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL ~ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR City of Santa Ana Linda Kelley 20 Civic Center Plaza Santa Ana CA 92702 @ACORD CORPORATION 1988 ACORD 25 (2001/08)