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<br />,ACORD. CERTIFICATE OF LIABILITY INSURANCE CSR PF I DATE (MMIDDNYYY) <br />SYMCO-1 01/25/05 <br />PRODUCER THIS CERTIFCATE IS ISSUED AS A MATTER OF INFORMATION <br /> ONLY AND CONFERS NO RIGHTS UPON THE CERTIFCATE <br />Burnette Insurance Agency, Inc. HOLDER. THIS CERTIFICATE DOESNOT AMEND, EXTEND OR <br />3447 Lawrenceville Suwanee Rd. ALTER THE COVERAGE AFR:lRDED BY THE POLCIES BELOW. <br />Suwanee GA 30024-2402 I INSURERS AFFORDING COVERAGE , <br />Phone: 770-339-B888 Fax: 770-339-1442 I NAIC# <br />INSURED A-;;<lYJ I-I y~ I INSURER A: Zurich U.S. Insurance f----- <br /> A- C/ODJ_I'N ~SURER B: Legion Insurance compan=-=~._ <br /> 80500 Group Inc. A-,>-OfJ3 -1/2- INSURER c: <br /> 1 5 Sate1l~te Blvd. Suite 5 I rNsuR_ER D: -t---- <br /> Suwanee GA 30024 A -4l.Y! -[J9% <br /> INSURER E: <br /> <br />COVERAGES <br /> <br />THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING <br />ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR <br />MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO All THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH <br />POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br /> <br />l TR NSR <br /> <br />A <br /> <br />TYPE OF INSURANCE <br />I GENERAL L1A~ILlTY <br />1- <br />I.X I COMMERCIAL GENERAL LIABILITY <br /> <br />EP C~~S MADE ~ OCCUR I <br /> <br />Ixl~' GEN'lAGGREGATE LIMIT APPLIES PER: I' <br />, PRO- n <br />X POLICY I JECT LOC <br />~OMOBILE LIABILITY <br />X ANY AUTO <br />U ALL OWNED AUTOS <br />~j SCHEDULED AUTOS <br />X HIRED AUTOS <br />~ NON-OWNED AUTOS <br />LI <br /> <br />POLICY NUMBER <br /> <br />, ~~';!N~fDE.f,wE I P8k!&~tb't-m.~ LIMITS <br />I ~~~~OCCURRENCE $1,000 r 000 <br />07/31/05 I PREMISES (Ea occurence) $ 300,000 <br />MED EXP (Anyone person} '$ 10 f 000 <br />I PERSONAL &-ADV INJURY 1$1,000 f 00-0- <br />I GENERAL AGGREGATE ~OO r 000 <br />PRODUCTS" COMPIOP AG~I $ 2 faD 0 f 000 <br /> <br />I COMBI~EDSINGLElIMrT 1$1 000 000 <br />07/31/05 (EaaCCldenl) .~. f <br />I BODilY INJURY I $ <br />(Per person) <br />r----:- . <br />BODILY INJURY I <br />l(pera~Cident}_ $_. <br />I PROPERTY DAMAGE ~ <br />I (f-'eraccldent) <br /> <br />07/31/04 I <br /> <br />040972979 <br /> <br />A <br /> <br />040972979 <br /> <br />1 <br />07/31/04 <br /> <br />GARAGE LIABILITY <br />o ANY AUTO <br /> <br />NOT APPLICABLE <br /> <br />AUTO ONLY - EA ACCIDENT $ <br />1 OTHER THAN EAA~-~. <br />AUTO ONLY: <br /> <br /> <br />EXCESS/UMBRELLA LIABILITY <br />A ~ OCCUR Li CLAIMS MADE <br /> <br />h DEDUCTIBLE <br />rx-I RETENTION $ 0 <br />WORKERS COMPENSATION AND <br />I EMPLOYERS' LIABILITY <br />B ,ANY PROPRIETOR/PARTNER/EXECUTIVE <br />I OFFICER/MEMBER EXCLUDED? <br />II yes. describe under <br />SPECIAL PROVISIONS below <br />I OTHER <br /> <br />040972979 <br /> <br />07/31/04 <br /> <br />07/31/05 <br /> <br />AGG $ <br />EACHOCCURRENC~OOO <br />I AGGREGATE_~_ $ 1 r 0.00 f 000 <br /> <br />~---~~--- <br />~-~~- <br />$ <br />X TORY LIMITS I ER <br />, E.l.EACHACCIDE~rOOO <br />,I E.l. DISEASE - EA EMPlOYE~ lOaf 000 _ <br />E.L. DISEASE. POLICY LIMIT I $ 500 f 000 <br /> <br />WC50548357 <br /> <br />11/28/04 <br /> <br />11/28/05 <br /> <br />DESCRIPTION OF OPERATIONS / LOCATIONS {VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS <br />Certificate holder is listed as additional insured as per contractual <br />obligation./Faxed 714-647-5406.SEE REVISED WC INFORMATION. <br /> <br />1 <br />APPROVED AS 10 Hh",. <br /> <br />,j'V/ , <br />/' ~7t "JC~ <br />. Laura Stitt SliecJy..... <br />Assistant Citv At1(1]":,_' <br /> <br />CERTIFICATE HOLDER <br /> <br />CANCELLATION <br /> <br />SANTAAN <br /> <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRA TIO <br />DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL ~ DAYS WRITTEN <br />NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL <br />IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR <br /> <br />Ci ty of Santa Ana <br />Linda Kelley <br />20 Civic Center Plaza <br />Santa Ana CA 92702 <br /> <br /> <br />ACORD 25 (2001/08) <br /> <br />@ACORDCORPORATlON 1988 <br /> <br />