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<br />From: Sandi WFredericksen At: VVood-Gutmann Insurance Brokers FaxlD: 714-573-1772 To: Laura/City of Santa Ana
<br />
<br />Date: 3/1512005 11:00 AM Page: 2 of 5
<br />
<br /> .
<br />ACORD. CERTIFICATE OF LIABILITY INSURANCE CSR SF I DATE (MMIDDIYYYY)
<br />CATHL-1 03/15/05
<br />PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
<br />Wood-Gutmann Insurance Brokers ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
<br />License #0679263 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
<br />14192 Franklin Ave" suite 200 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
<br />Tustin CA 92780-7044
<br />phone:714-505-7000 Fax:714-573-1770 INSURERS AFFORDING COVERAGE NAIC# ..
<br />---- - ---- - --- - -- ---- -- -- ----- - f- -----
<br />INSURED ¡J - ,).{'[' <j-{q,s- 1'1 INSLkekA zurich US _+..1.930~
<br /> ---- ---- ---- - - ---
<br /> INSIJR='"II:)
<br /> Cathleen Forcucci Dance 'NSURERC
<br /> Acad~, Fullerton
<br /> 3040 ry st INSI!RFRD
<br /> Riverside CA 92506
<br /> INéJJRERE
<br />
<br />COVERAGES
<br />
<br />THE POLICeS OF INSURANCe LISTED I::H:LOW HA'/E 8EC::N 1:S:SUED TO THE Ir,:SURED NAMED AbOVE FOR THE POLICY ~::;;>IOD INUIC.,o,TEJ NOTWIIHSTA.NDlr'JG
<br />ANY REOUIREMENT, TEr<M OR C0~IDIT'ON OF ,ANY CONTRACT OR OTHER DOCUME'iT WTH RESPECT TO WHICH THIS CERTIFICA-E MAY BE ,sSUED OR
<br />MAY PERT,A,IN, THE I'-JSURAr.;CE ,"J'FüRDED BY THE POLICIE::, DESCR'BED HEREIN IS SUBJECT TC ALL TH:: TERMS. EXCLUSIONS AND CONDITIONS OF SUCH
<br />F<JLlCIL0 Ar;GR:::~AIL LIMII S SHOWN MAY HAVE B[[N Rl::UUCED BY PAI0 CLAIMS
<br />
<br />--
<br />
<br />---~1';!~T~ PgMi:Y(~~bt(t~~N--~
<br />EACH OCCURRE~ICE
<br />
<br />LTR NSR
<br />
<br />TYPE OF INSURANCE
<br />GENERAL LlABIUTY
<br />X COMMl:::kClAL (;;ENE;;:AL Llf\J:Jlury
<br />. . Cl AIMS MADE ~ OCCUR
<br />.X *Tenant Legl Liab
<br />
<br />POLICY NUMBER
<br />
<br />12/04/05
<br />
<br />12/04/04
<br />
<br />042823782
<br />
<br />PREMI:SES(Eaoccufercel
<br />MFDEXP(Anyonopiw'on)
<br />P;::RSONAL & ADV INJlJRY
<br />
<br />A
<br />
<br />C-EN'l AGGREGATE LIMIT APPLIES PER
<br />I-'RO-
<br />.,ECT
<br />AUTOMOBILE LIABILITY
<br />
<br />GENERAL AGGREGATE
<br />rRODUCTS - COMP/OF' AGe
<br />
<br />
<br />LOC
<br />
<br />COM8:Nl::U :SINGLE llMll
<br />12/04/05 ,(Eailc~ldent)
<br />
<br />A
<br />
<br />042823782
<br />
<br />12/04/04
<br />
<br />--
<br />
<br />ANY AUTO
<br />ALL OWNeD AUTOS
<br />
<br />BODILY INJURY
<br />(Per person)
<br />
<br />:SCHi::JLlEO AUTOS
<br />X HIRE') !\UTOS
<br />X 'jON OWNED At !TOS
<br />
<br />RODILY'NJURY
<br />(Peracclde1t)
<br />
<br />rROPERTY DAMAGE
<br />(Peraccidel1t:,
<br />
<br />GARAGE LIABILITY
<br />
<br />I AJDONLY-EAACCDENT
<br />
<br />ANY AUTO
<br />
<br />OTHER'HAN
<br />AUTO ONLY
<br />
<br />EXCESS/UMBRELLA LlABILm'
<br />OCCUI-I D CLAIMS M.AlJl::
<br />
<br />[ACH OCCURRENCE
<br />AGGREGATE
<br />
<br />AS TO FOR
<br />
<br />::JEOUCTIBI f
<br />RETENTION
<br />
<br />,,['ROVED
<br />
<br />- /;.
<br />
<br />
<br />
<br />WORKERS COMPENSATION AND
<br />EMPLOYERS'lIABILITY
<br />ANY PROPRIETOR/PARTNERÆXECUTIVE
<br />OFFICER/MEMBER EXCLUDF[';?
<br />Ilyes,do,:-cribounds!
<br />SPECIAL PROVISIONS belo""
<br />OTHER
<br />
<br />, ,lllla Su
<br />,,-,¡:,iii(ìl (,j[V ~j\H()rnG\'
<br />
<br />I E L. EACH ACCIDENT ¡ $
<br />E l. DISEASE - EA EMPLOYEE $
<br />E L DISEA~[ - POllC'i LiM;T
<br />
<br />DESCRIP110N OF OPERATIONS / LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
<br />*10 Days for Non-payment of Premium, city of Santa Ana and their respective
<br />officers, employees, agents, volunteers and representatives are named as an
<br />additional insured per attached endorsement #CG20261185. waiver of
<br />Subrogation also applies per attached endorsement #CG24041093
<br />
<br />CERTIFICATE HOLDER
<br />
<br />CANCELLATION
<br />
<br />LIMITS
<br />
<br />$ 1,000,000
<br />$ *1,000,000
<br />$ 10,000
<br />11,0DO,OOO
<br />'$ 2,000,000
<br />, 2,000,000
<br />
<br />$1,000,000
<br />
<br />-.
<br />
<br />,$
<br />
<br />"
<br />
<br />[AACC $
<br />AGG $
<br />
<br />$
<br />$
<br />$
<br />,$
<br />I
<br />
<br />DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
<br />
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
<br />
<br />DAYS WRITIEN
<br />
<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 />REPRESENTATIVES.
<br />AUTH REPR ENTATIVE
<br />
<br />SANTAO 7
<br />
<br />City of Santa Ana
<br />peggy Calvert
<br />20 Civic Center Plaza
<br />Santa Ana CA 92701
<br />
<br />
<br />ACORD 25(2001/08)
<br />
<br />
<br />~e'¿
<br />
<br />*30
<br />
<br />RPORATION 1988
<br />
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