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iC__O__BD,M CERTIFICATE OF LIABILITY INSURANCE <br />I DATE 12/31/ZO03 MMIDDIYYYY) <br />12/31/2003) <br />PRODUCER (909)W-2719 FAX (909) 587 -6001 <br />Anthem Insurance <br />42145 Lyndi a Ln. , #202 <br />Temecula, CA 92591 <br />License # OB84551 <br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION <br />ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE <br />HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR <br />ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. <br />INSURERS AFFORDING COVERAGE <br />NAIC # <br />INSURED Boys and Girls Club of Santa Ana <br />950 Highland St <br />Santa Ana, CA 92703 <br />INSURER A- Markel Insurance Company <br />POLICY EFFECTIVE <br />INSURER <br />LIMITS <br />INSURER C. <br />INSURER D'. <br />8502CY073003 <br />INSURER E. <br />01/05/2005 <br />COVERAGES <br />THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDINI <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 />INSR <br />AGUE <br />TYPE OF INSURANCE <br />POLICY NUMBER <br />POLICY EFFECTIVE <br />POLICY EXPIRATION <br />LIMITS <br />GENERAL LIABILITY <br />8502CY073003 <br />12/20/2003 <br />01/05/2005 <br />EACH OCCURRENCE <br />$ 1,000,000 <br />COMMERCIAL GENERAL LIABILITY <br />DAMAGE TO RENTED <br />$ 50,000 <br />CLAIMS MADE ❑ OCCUR <br />MED EXP (Any one person) <br />$ 5,0()0 <br />PERSONAL &ADV INJURY <br />$ 1,000,000 <br />A <br />X <br />GENERAL AGGREGATE <br />$ 3,000,000 <br />GEN L AGGREGATE LIMIT APPLIES PER <br />PRODUCTS - COMP /OP AGE <br />$ 1,000,000 <br />POLICY PRO- LOC <br />ECT <br />AUTOMOBILE <br />LIABILITY <br />1002CYCO730044 <br />12/20/2003 <br />01/05/2005 <br />COMBINED SINGLE LIMIT <br />ANY AUTO <br />(Ea accident) <br />$ <br />1,000,000 <br />BODILY INJURY <br />$ <br />ALL OWNED AUTOS <br />SCHEDULED AUTOS <br />(Per person) <br />A <br />X <br />BODILY INJURY <br />$ <br />HIRED AUTOS <br />NON OWNED AUTOS <br />(Per accident) <br />PROPERTY DAMAGE <br />$ <br />(Per accident) <br />GARAGE LIABILITY <br />AUTO ONLY - EA ACCIDENT <br />$ <br />OTHER THAN EAACC <br />$ <br />ANY AUTO <br />$ <br />AUTO ONLY. AGO <br />EXCESSIUMBRELLALIABILITY <br />4602CY0730105 <br />12/20/2003 <br />01/05/2005 <br />EACH OCCURRENCE <br />$ 5,000,000 <br />OCCUR ❑CLAIMS MADE <br />AGGREGATE <br />$ 5,000,000 <br />A <br />X <br />$ <br />$ <br />DEDUCTIBLE <br />X RETENTION $ 10,00 <br />$ <br />WORKERS COMPENSATION AND <br />- <br />WC STATU- <br />_ <br />EMPLOYERS' LIABILITY <br />^�? <br />A .NY PROPRIETOR /PARTNERiEiECUTIVE <br />ER /MEMBER EXCLUDED' <br />-�J� <br />E. L. EACH ACCIDENT <br />$ <br />E. L. DISEASE - EA EMPLOYEE <br />$ <br />IOtyee <br />I_ <br />�/� <br />SPECIAL PROVISIONS below <br />(. :. <br />E. L. DISEASE - POLICY LIMIT <br />$ <br />OTH <br />10 Nay cancel non <br />payment of premium <br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS <br />E: City of Santa Ana, its officer, agents and employees are named as additional insured <br />as respects the operations of the named insured. <br />City of Santa Ana <br />20 Civic Center Plaza <br />Santa Ana, CA 92701 <br />ACORD 25 (2001108) <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE <br />EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL iWOWHM MAIL <br />30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, <br />YJtd4�li1( NcY�C-0 H6NaXM�GIEi( 1( dfAfd( J§ 1LiXIXNdWf3EYl (d(Xi4XdWiX�14X9EX16Y114X3(XX <br />©ACORD CORPORATION 1988 <br />"4V <br />