ARDENT ERGONOMICS (MELGOZA, JORGE)

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®�� CERTIFICATE OF LIABILITY INSURANCE DATE(MWDDIYYYY) 12/04/2024 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT LAZARO NETO NAME: Statefarm LAZARO NEfO (619)-229-6799 plc No: (619)-229-6796 ift 3924 EL CAJON BLVD. gk:d�,—.,T,.ro.neto.m36f@statefarm.com aooesss: lazaro.neto.m36f@statefarm.com INSURERS AFFORDING COVERAGE NAIC N INSURERA: State Farm General Insurance Company 25151 SAN DIEGO CA 92105 INSURED INSURER e : State Farm Mutual Automobile Insurance Company 25178 MELGOZA, JORGE B INSURER C : 6867 GOLFCREST DR APT 51 INSURER D INSURER E: SAN DIEGO CA 92119 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILT R. TYPE OF INSURANCE ADDLSUBR Man "D POLICYNUMBER POLICYEFF MM/DDIYYYY PODCYEXP MM/DD/YYYY LIMITS COMMERCIAL GENERALLIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE OCCUR DAMAGE TO RENTED PREMISES Ea occurzence $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL B ADV INJURY $ 1,000,000 A Y Y 90-E3-K874-5 10/15/2024 10/16/2025 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY D PRO- ❑ LOG JECT GENERALAGGREGATE $ 2.000,000 PRODUCTS-COMP/OP AGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY 583 7885-Dl5-55 10/15/2024 04/15/2025 COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Par person) $ 1,000,000 ANY AUTO BODILY INJURY Per accident) ( ) $ 1,000,000 A OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE Per acoidem $ 1,000,000 $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAR CLAIMS -MADE DEO RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED' NIA STATUTE ER E.L. EACH ACCIDENT $ $ (Mandatory in NH) If yes, describe under E.L. DISEASE - EA EMPLOYE $ DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The City, its officers, officials, employees, and volunteers are to be covered as additional insureds and waiver of subrogation on the CGL policy with respect to liability arising out of work or operations performed by or on behalf of the Consultant including materials, parts, or equipment furnished in connection with such work or operations oisaalq:�9,,.a Tu Tran 9 . �n APPROVED Nguyen emy By Tu Tran Nguyen at 9:12am, Feb 26, 2025 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CITY OF SANTA ANA ACCORDANCE WITH THE POLICY PROVISIONS. 20 CIVIC CENTER PLAZA AUTHORIZED REPRESENTATIVE SANTA ANA, CA 92702 4"a&9 Xl/P OE) 1988-2015 ACORD CORPORATION. All rinh$s resarvud ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 1001486 132849.12 03-16-2015