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_ /18 AC-ORD.. CERTIFICA" _ LIABILITY INSURQ"CF' DATE <br />PRODUCER (909) 571 -6077 FAX (909) 587 -6001 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION <br />Anthem Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE <br />42145 L ndi a LIT., #202 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR <br />Y ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. <br />Temecula, CA 92591 <br />License # OB84SS1 <br />INSURED Boys and Girls Club <br />950 Highland St <br />Santa Ana, CA 92703 <br />CFIVFRAnFS <br />INSURERS AFFORDING COVERAGE <br />INSURER A: Markel Insurance <br />INSURER 8: <br />INSURER C: <br />INSURER D: <br />INSURER E: <br />NAIC # <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 />INSft <br />1111. <br />ADD'L <br />tNSR <br />TYPE INSURANCE <br />POLICY NUMBER <br />POLICY EFFECTIVE <br />POLICY EXPIRATION <br />LIMITS <br />GENERALLIABILITY <br />8502CY073003 <br />12/202003 <br />01/05/2005 <br />EACH OCCURRENCE <br />E 1,000,00 <br />COMMERCIAL GENERAL LIABILITY <br />DAMAGE TO RENTED <br />PREMISES IF, rrrs,rerll) <br />E 50,000 <br />CLAIMS MADE ❑ OCCUR <br />MED EXP (Any one person) <br />E 5,000 <br />A <br />PERSONAL S ADV INJURY <br />E 1,000,000 <br />GENERAL AGGREGATE <br />E 3,000,00 <br />GEN -L AGGREGATE LIMIT APPLIES PER <br />PRODUCTS - COMP /OP AGG <br />E 1,000,00 <br />POLICY PRO- EGT LOC <br />J <br />AUTOMOBILE <br />LIABILITY <br />ANY AUTO <br />1002CYC0730044 <br />12/20/2003 <br />01/052005 <br />COMBINED SINGLE LIMIT <br />(Ea accident) <br />E <br />1,000,00 <br />A <br />ALL OWNED AUTOS <br />SCHEDULED AUTOS <br />BODILY INJURY <br />(Per person) <br />E <br />BODILY INJURY <br />(Per accident) <br />f <br />HIRED AUTOS <br />NON -OWNED AUTOS <br />PROPERTY DAMAGE <br />(Per accident) <br />s <br />GARAGE LIABILITY <br />AUTO ONLY - EA ACCIDENT <br />E <br />OTHER THAN EA ACC <br />S <br />ANY AUTO <br />$ <br />AUTO ONLY -. AGG <br />EXCESS/UMBRELLA LIABILITY <br />4602CY0730105 <br />12/20/2003 <br />01/05/2005 <br />EACH OCCURRENCE <br />E 5,000,00 <br />OCCUR ❑ CLAIMS MADE <br />AGGREGATE <br />E 5,000,00 <br />A <br />.t'iLI �t <br />E <br />E <br />DEDUCTIBLE <br />X RETENTION E 10,00 <br />E <br />WORKERS COMPENSATION AND <br />EMPLOYERS' LIABILITY <br />ANY PROPRIETOR /PARTNER/EXECUTIVE <br />_ <br />- L <br />- <br />WCSTATU- OTH- <br />E.L. EACH ACCIDENT <br />E <br />E.L. DISEASE - EA EMPLOYE <br />E <br />OFFICER /MEMBER EXCLUDED? <br />N yes, describe under <br />i - -.�. <br />E.L. DISEASE - POLICY LIMIT <br />E <br />SPECIAL PROVISIONS below <br />- <br />OTHE <br />10 ay cancel non <br />ayment of premium <br />DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS <br />E: Community Development Block Grant - Certificate holder is named as additional insured <br />as respects the operations of the named insured. <br />City of Santa Ana <br />attn: Carla Thompkins <br />20 Civic Center Plaza M -25 <br />Santa Ana, CA 92702 <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE <br />EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL IklMOLM MAIL <br />30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, <br />X K7( A4ifDb` O6lDOGXA( KdfiYd�14XIXNd4klf] (Md004XdFJf1NSX>1fXd6YJ(L1(1(XX <br />REPRESENTAME <br />ACORD 25 (2001/08) rHA: Luv /owy -DDwy OACORD CORPORATION 1988 <br />