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- ,ACORD. CERTIFICATE OF LIABILITY INSURANCE CSR PF I DATE (MMIDDIYYYYJ SYMCO-1 01/25/05 PRODUCER THIS CERTIFCATE IS ISSUED AS A MATTER OFINFORMATION ONLY AND CONFERS NO RIGHTSUPON THE CERTIFCATE Burnette Insurance Agency, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 3447 Lawrenceville Suwanee Rd. ALTER THE COVERAGE AFFORDED BY THE POLI:IES BELOW. Suwanee GA 30024-2402 I I Phone: 770-339-B888 Fax: 770-339-1442 INSURERS AFFORDING COVERAGE I NAIC #--- INSURED A-:/L'O I-I S'~ ----lINSURERA: Zurich U. S. I~surance A - .;;oOd- JLI'-/ ~SURER B Legion Insura~ce Company f---~ S~co GrouPf: Inc. A-;)..003 -I/Z I INSURER c: r .- 1 5 Sate11~ e Blvd. Suite 5 , INSURER 0: Suwanee GA 30024 A-~-o'l% I INSURER E' I -- 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 SUBJECTTQ ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS I COVERAGES L TR NSR TYPE OF INSURANCE I GENERAL lIAalllTY I~ I ~MMERCIAL GENE~L1ABILlTY , ~' CLAIMS MADE ~ OCCUR I I..J_ I Ixl~- GEN. 'LAGGREGATE LIMIT APPLIES PER: I X 'PRO." POLICY I JECT _ LOC ~OMOBILE LIABILITY ~ ANY AUTO I I ALL OWNED AUTOS q SCHEDULED AUTOS ~ HIRED AUTOS rl NON-OWNED AUTOS r~ A A A f GARAGE LIABILITY HI ANY AUTO ~ESSJUMBRElLA LIABILITY ~~ OCCUR ~ CLAIMS MADE n DEDUCTIBLE RETENTION $ 0 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ~~E~11IS~~boJr~7o~s below OTHER B POLICY NUMBER POITC'i'EFFEC1WET~'fEXl5IRA I N DATE MMIDDIYY) I DATE MMfDDfYY 07/31/041 07/31/05 I ~~~~~;7~~~~~~~ $ 1 , 000 , 000 ~EMISES(Eaoccurence) ~ $ 300,000 ~EDEXP(Anyoneperson} $10,000 I PERSONAL &'ADV INJURY 1$1,000,000 GENERAL AGGREGATE $ 2,000,000 I PRODUCTS-COMPJOPAGG $ 2,000,000 LIMITS 040972979 040972979 07/31/05 I COMBI~EDSINGLELlMIT $1 000 000 (EaBccldent) ~' I BODIL~ INJURY I $ I (Per person) I BODIL~NJUR~ (Peraccidenl) 1$ r--~---+---- PROPERTY DAMAGE I $ (f-eraccldent) ! 07/31/04 I NOT APPLICABLE ~TO ONLY - EA ACCIDENT ,$ , OTHER THAN EA ACC ~ I AUTO ONLY. - AGG _ $ ~ACHO~_~~ OOO--Lo.~ pGGREGATE .__ ! $ 1,000,000 r------__+;___ ~-----_r.__ . r X TORY LIMITS I ER - E.LEACHACCIDENT ~,OOO I E.L. DISEASE - EA EMPLOYEE~ 10 O~--oo-- E.L. DISEASE - POLICY LIMIT I $ 500 / 000 040972979 07/31/04 07/31/05 I WC50548357 I I I I 11/28/04 11/28/05 I ApPROVED AS! 0 to",., DESCRIPTION OF OPERATIONS' LOCATIONS I VEHICLES' EXCLUSIONS ADDED BY ENDORSEMENT' SPECIAL PROVISIONS Certificate holder is listed as additional insured as per contractual obligation./Faxed 714-647-5406.SEE REVISED WC INFORMATION. CERTIFICATE HOLOER City of Santa Ana Linda Kelley 20 Civic Center Plaza Santa Ana CA 92702 ACORD 25 (2001/08) ~~a~r~'S;lt:;I~~Y ..... Assistant City ,1\.(101"),'. CANCELLATION SANTAAN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRA TIO DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL ~ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR @ ACORD CORPORATION 1988