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<br />CERTIFICA~ U~!JILITY INSURAaE
<br />
<br />THIS CERJlIFICATE 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 />
<br />.I
<br />
<br />ACORDN
<br />
<br />PRODUCiA
<br />
<br />COLONIAL SOUTH BAY INSURANCE
<br />11859 INGLEWOOD AVENUE
<br />HAWTHORNE, CA 902S0
<br />
<br />BROKERS
<br />
<br />oaTE (MUIODIY'f)
<br />
<br />
<br />INSURED
<br />
<br />..~~,~UI'lE" A
<br />: INSUAEA B
<br />INSuRER C
<br />
<br />INSURERS AFFORDING COVERAGE
<br />z:uR.lCUINSURANCE"'COMPAlIlT'- U
<br />-sTA'TE NATIONAL INSuJ:(.II.Ncl> CO;""
<br />'~I:5OTr IN'SURANCECOl'lP1WY" ',---
<br />
<br />LIEN ON ME, INC.
<br />P.O. BOX 91630
<br />PASADENA, CA 91109
<br />
<br />INSuRER D
<br />",-"",.__0'"
<br />
<br />INSUAE~ E
<br />
<br />COVERAGES
<br />
<br />THE POLICIES OF INSURANCE L1STED8ELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING
<br />ANV REOLIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH TI<IS CERTIFICATE MAY BE ISSUED OR
<br />MAY PEF4T AIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 15 SUBJECT TO All THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCt-t
<br />pOL.lCIES AGGREGATE LIMITS SHOWN MAY HAVE BEEN REOtJCED ov PAID CLAIMS
<br />
<br />fN'" TYIIlI: OJ: INSUIiIANCf. "----;;,~~; NUII8E'- POliCY EFFECTlVt' ,-Ci:tCTE"fi1~l'lDN"'
<br />
<br />~~NIE"&lLlABfLITY
<br />A X C",,""EAOALGENEAALLlA8IL1TV PAS-38700846
<br />j Cl"IMS MADE :' ~ OCCUR
<br />
<br />8-1S-02
<br />
<br />18-1S-03
<br />
<br />,
<br />"
<br />
<br />
<br />AuTOMOBILE UA811ITY
<br />A lX 'ANY AUTO
<br />,,'- "-I ALL OWNH.l AUTOS
<br />- SCHEDvLED AUTOS
<br />r I HIRED AuTOS
<br />..=.. NON-OWNEO AU10S
<br />
<br />IPAS-38700846
<br />
<br />18-1S-02
<br />
<br />8-15-03
<br />
<br />1.._~"aGE llA81L1TY
<br />. __ j "NY aUTO
<br />
<br />B E~'::~~:INI."'Yf"" ] C~IMS MADE
<br />i-l
<br />Of.DUCTl9L~
<br />RETENTION S
<br />I' woIllKEIiIISCOMPiEN5A'IOIN "ND
<br />l....lOYfIllS. LiaBILITY
<br />
<br />SCU-002602
<br />
<br />8-15-02
<br />
<br />8-lS-03
<br />
<br />. I
<br />I,aRM
<br />
<br />VED AS Iro
<br />
<br />lau~4
<br />
<br />) )
<br />
<br />r-
<br />
<br />_cpu
<br />
<br />C OTHfIli
<br />I PROFESSIONAL
<br />LIABILITY
<br />DlSCRI""ION OF Op~ATIO"SlLOC"TIO"'SlVEJ4ICLIBI(XC"'U6ION8 ADDED.V ENDORSEM(NTISPECIAL PROvlSlONIi
<br />
<br />SPL-0006456
<br />
<br />~-2S-02
<br />
<br />~-25-03
<br />
<br />LIMITS
<br />
<br />_~~Et:!?S~~~_"'~,~NCE _$__ ~1._QJ?Q" o~ ,9
<br />'1=_1~~.E~~~~EJ.~.~W._~I~Jlr~l .~_,___}QO" OQQ
<br />_~_f,~ ~,~,~_IA"yo~e"p~I,~~,~.",,_ ,s ____..~9.t__9_Q._O
<br />PE,f'_~_2~.~.~_~l?~~~~,~V "!._~~_9"QJ0._q_Q 0
<br />. 06"""'~_A~. A~..9~EGATE ,4 , 000 . 000
<br />'_.P~OO~~TS:_.C;q~P/O" ~O~_~" ~'~Q_~~() !.cHfO
<br />
<br />I COMBtNED SINGLE: LIMIT
<br />tE....ccld."1)
<br />r----..'" .-...... -,," "--,,..,--
<br />
<br />s..,~, OO~..900
<br />
<br />6001L V INJUAV
<br />I (Per p.r,.cm) '_'."_I_~~
<br />BOOI~ v INJURY , S
<br />(pe'lccidenl) I
<br />~~?:~c7~~g.M;~~'-.U ',.
<br />1:~~::~EAAo:~;~~~.~
<br />
<br />Jl,ul'OONLV AGe> ,
<br />
<br />f_~_~~ OCC~~_~~~c:~
<br />AGOAfOATE
<br />1------ ---.-
<br />I
<br />
<br />
<br />~1,OOO,OOO LIMIT
<br />$5,000 DEDUCTIBLE
<br />
<br />10 DAYS NOTICE OF CANCELLATION FOR NON-PAYMENT
<br />THE CITY OF SANTA ANA, ITS AGENTS, OFFICERS AND EMPLOYEES ARE NAMED AS ADDITIO
<br />NAL INSUREDS (See attached schedule)
<br />
<br />CERn FICA TE HOL.DER X AODfTK*U'L INSURED; INSUAf.JII. LETTIER
<br />CITY OF SANTA ANA
<br />WORKERS COMPENSATION CLAIMS ADM.
<br />20 CIVIC CENTER PLAZA (M-41)
<br />SANTA ANA, CA 92701-1988
<br />Attn, Rosa Flores
<br />Via fax: 714-647-5311
<br />
<br />CAIlCELLATlON
<br />SHOULD AN., Cl)F n~. "BOYlE oCSCAIBED POLlCll!~ 815ANCtLLED BE;FOIfE THE UPIIl'IIATION
<br />DAn: 'tHEREOF, TNI!' 'SI\M..Q INSURER WILL INw./oI.lo MAll ~ _~ 0.....9 -rrTI!N
<br />NOTICE 'to YNIE CE:RTIF'ICaU HOLDI!A NAMED T THE LEFT, ~l""'f'l-'TfJ 1ct'/i ,~y..
<br />1''''''''''''1'1"'1'''' '1~'1I'f''''' """P'f'~"""''''''''f'1".m''''l
<br /><
<br />
<br />
<br />ACORD 25-5 (7197)
<br />
<br />m 39\1d
<br />
<br />nSNI ^\18 5 1\1IND1DJ
<br />
<br />....,/--
<br />
<br />1: 1513EL5
<br />
<br />13~ :513 1:13131:181150
<br />
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