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<br />~ 2/10/}004 15:24
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<br />Ii ::)()93' JI2.. Burnet te Insurance
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<br />Pam F1owers~LAlJRA SHEEDY
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<br />2i2
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<br />ACORD. CERTIFICATE OF LIABILITY INSURANCE CSR PF I DATE (MMIOOiYYVY)
<br />SYMCO-1 02/10104
<br />PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
<br /> ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
<br />Burnette Insurance Agency/Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
<br />3447 Lawrenceville Suwanee Rd. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
<br />Suwanee GA 30024-2402
<br />Phone: 170-339-8888 Fax: 770-339-1442 INSURERS AFFORDING COVERAGE NAlC#
<br />IN!!IURED A-.aoO/~ IEJ4 INSURER"'- Zurich u.s. Insurance
<br /> 4:, ;00,).' I INSURERS Legion Insurance Company
<br /> IN5UFlERC
<br /> Sma Grou~, Inc. '+~~3. 11)-
<br /> 3 73 McCa1 Dr #1 INSURER 0
<br /> Atlanta GA 30340-2831
<br /> INSURERE:
<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 PNf CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUEO 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 />'~~ :u~ TYPE OF INSURANCE POUCY NUMBER p~~r':~~~ Pg~ieYf~:'o~~~ U"no
<br /> GENERAL LlABIUTY EACH OCCURRENCE , 1,000,000
<br /> - 07/31/03 07/31/04 ~ES(E;~;~~~nce)
<br />A l[ COMMERCIAL GENERAl... LLABIUTY 040972979 , 300,000
<br /> II!:LAlMSM.4J)E [!] OCCUR MED EXP (Anyone person) , 10,000
<br /> PERSONAL & f.lN INJURY $ 1/000,000
<br /> -
<br /> - GENERAL AGGREGATE S 2/000,000
<br /> / GEN'lAGGREGATE UMIT APPUES PER: PRODUCTS. COMPIOP AGG S 2/000,000
<br /> Xl. neRO- nLOC
<br /> :J: I POUCY JECT
<br /> ~OM08ILE LIABILITY COMBINED SINGLE UMIT $ 1/000,000 I
<br />A X ANfAUTO 040972979 07/31/03 07/31/04 (EaacCident)
<br /> - I
<br /> ALL OWNED AUTOS BODILY INJURY
<br /> - ,
<br /> SCHEDULED AUTOS (Per person)
<br /> - I
<br /> ..!.. HIRED AUTOS BODILY INJURY
<br /> ,
<br /> ..!.. NON-OWNED AUTOS (Peracctdent)
<br /> - PROPEF:lTY DAMAGE ,
<br /> (Per accident)
<br /> =r::;~ AUTO ONLY - EA ACCIDENT ,
<br /> NOT APPLICABLE OTHERTHA.N EAACC ,
<br /> AUTO ONLY AGG ,
<br /> ~=r~SJUMBREL.LA LIABILITY EACH OCCURRENCE , 1 000,000
<br />A X OCCUR D CLAIMS MADE 040972979 07/31/03 07/31/04 AGGREGATE , 1,000,000
<br /> i
<br /> , I
<br /> ~:'OUCT"LE , i
<br /> :J: RETENTION '0 , I
<br /> WORKIRI COMPENSATION AND :x I T~gyS~~~~ I lo~:t
<br />B EMPLOYERS'LlABIUTY WC50548357 11/28/03 11/28/04 , 100,000
<br />/>NY PROPRIETORJPARTNER/B(ECUTNE E.L. EACH ACCIDENT
<br /> OFFICERlMEMBER EXCLUOED? E.L. DISEASE. EA EMPLOYEE , 100,000
<br /> lfyes,descnbeunder , 500,000
<br /> SPECIAL PROVISIONS below EL DISEASE. POUCY UMIT
<br /> ""'ER I
<br /> I
<br /> ,
<br /> ,
<br />DESCRlftTlON OF OPERATIONS I LOCATIONS I VEHICLES / EXCLUSIONS ADDED IY ENDORSEMENT I SPECIAL PROVISIONS tr t {l.PPROVm) F\S TO ~f.'OB.1\,1 I
<br />Certificate holder is listed as additional insured as per con ac ua I
<br />obliqation./Faxed 714-647-5406.SEE REVISED WC INFORMATION. .-~jjf.-----
<br /> i
<br /> ,-- ;r,- (", . -';,.._., .1.. ,
<br /> L'ILdd ..),~.rc :-;l"''-'~'''"'_: I
<br /> Assistani City }', trnri,I~\
<br />
<br />CERTIFICATE HOLDER CANCELLATION
<br />
<br />SANTAAN' SHOULD ANY OF THE ABOVE DESCRlSED POUCIES BE CANCELLED BEFORE llIE EXPlRA110N
<br />
<br />DATE YHEREOF, YHE ISSUING INSURER WILL ENDEAVOR TO MAlL
<br />
<br />30 DA'tS WRmEN
<br />
<br />City of Santa Ana
<br />Linda Kelley
<br />20 Civic Center Plaza
<br />Santa Ana CJi 927C2
<br />
<br />NOTICE TO THE CERTIFICATE HOLDER NAMED TO THI> LEFT, BUT FAlLURI> TO 00 50 5HAU
<br />IMPOSE NO OSLlGA110N OR UABIUTY OF ANY KIND UPON THE INSURER. ITS AGENTS OR
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