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ACORD, CERTIFICATE OF LIABILITY INSURANCE CSR PF I DA.TE jMM1DDNYYY) SYMCO 1 07/13/04 PRODUCE~ THIS CERTIFICATE IS ISSUED AS A MATTER OFINFORMATION ONLY AND CONFERS NO RIGHTSUPON THE CERTIFCA TE 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 I Phone: 770-339-BB88 Fax: 770-339-1442 I INSURERS AFFORDING COVERAGE \ NAIC# INSURED I INSURER A Zurich U.S. Insurance I i INSURER B Leaion Insurance Company I s~co Group Inc. I INSURER c I 1 5 Sate11~te Blvd. Sui te 5 !INSURER 0 I Suwanee GA 30024 \ INSURER E: I COVERAGES THE POLICIES OF INSURANCE LISTED 8ElOW HAVE BEEN ISSUED TO 1HE INSURED NAMED ABOVE FOR THE POLlCY PERrOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFJCA TE 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, AGGRE::.GATE LIMITS SHOWN MAY HAVE BEEN REDUCED. BY PAID CLAIMS. L TR INSRC TYPE OF INSURANCE POLICY NUMBER i rou~~l~MIDDN'v ' : ~gi!(EYfijXJ;~~~N I liMITS I GENERAL L.IABIUTY I I EACH OCCURRENCE 1'1,000,000 A [Xl CatERCIAL GENERAl LIABILITY I 040972979 07/31/04 i 07/31/05 I PREMISES (Ea occlJre.nce) .' 300 ,000 I CLAIMS MADE ~ OCCUR I MEa EXP (Anyone person} 1,~o,ooO I I PERSON!\l &. !\DV INJURY !' ~,000, 000 I GENERAL AGGREGATE I, 2,000,000 ~L AGGREOATE LIMIT APPLIES PER' PRODUCTS,COMP/OPAGG I $ 2,000,000 \X POLICY n j~8T n LOC I I J ~aMaBILE LIABILITY I I COMBINED SINGLE UMIT I X ANY AUTO 040972979 I 07/31/04 07/31/05 I (Ea accident) 1'1,000,000 ALL OWNED AUTOS ~7 B001L Y INJURY \, W SCHEOULED AUTOS (Per person) \ ~ HIRED AUTOS //~ I ~ODIL Y INJURY I , I X NON-OWNED AUTOS \per ~ccldenl) )' H i PROPERTY DAMAGE 1 I I I (Per~cclljent) i' , pRAGE LIABILITY I AUTO ONLY - EA ACCIDENT , ANY AUTO NOT APPLICABLE laTHER THAN EA ACe , ; I AUTO ONLY AGG , ~ESS'UMBRELLA LIABILITY \ EACH OCCURRENCE '1,000,000 A [!J OCCUR n CLAIMS MADE 040972979 07/31/04 07/31/05 I AGGREGATE , 1,000,000 f- ! .' U DEDUCTIBLE t I, IX I RETENTION '0 I, 1 WORKERS COMPENSA. TION AND X I T'8~l ~,~Ws i iV~~-1 EMPLOYERS' LIABILITY WC50548357 11/28/03 11/28/04 1'100,000 B ANY PROPRIETOR/PARTNER/EXECUTIVE E.L EACH ACCIDENT OF'FICERlMEMBER EXCLUDED? EL DISEASE - EA EMPLOYEET $ 100 , 000 ~P~i:'~Ls~~6v~s?6~s below I EL DISEASE - PQUCYUMlT ! $ 500 ,000 OTHER I I DESCRIPTION OF OPERATIONS f LOCATIONS f VEHICLES I EXCLUSIONS ADDEO BY ENDORSEMENT / SPECIAL PROVISIONS Certificate holder ~s listed as additional insured as per contractual obligation./Faxed 714-647-5406_SEE REVISED WC INFORMATION. CERTIFICATE HOLDER CANCELLATION SANTAAN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES Be CANCELLED BEFORE THE EXPlRA TIO DATE. THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL ~ DAYS WRlnEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LJABILlTY OF ANY KIND UPON THE INSURER, ITS AGENTS OR City of Santa Ana Linda Kelley 20 Civic Center Plaza Santa Ana CA 92702 (gACORD CORPORATION 1988 \CORD 25 (2001108) f#iJ