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INSURANCE COMpAKyWw=wlH AMERICA <br />AND <br />IES <br />'�� PACIFIC EfYERS GROUP OF INSURANCE CO <br />CERTIFICATE OF INSURANCE <br />(This Certificate of insurance neither ffirmatwelys of req,twely <br />emit ertificafes.) / %�t.• <br />or alters the coverage, <br />—I COMPANY CODES <br />is is to dLertd{I to I <br />Q ALLIED INSURANCE CO. <br />City of Santa Ana © INA OF TEXAS <br />Santa Ana, Californift 50 PACIFIC EMPLOYERS INSURANCE CO. <br />J OF NORTH E MERPICAY <br />L The Company as coded below, QA INA INS. CO. OF ILLINOIS <br />that the following described policy or policies, issued below, b have been issued to: <br />providing insurance only far hazards checked by © INA INS. CO. OF OHIO <br />NAME Southwest Little League Fo <br />AND (OTHER;– SPECIFY) <br />ADDRESF Santa pna f Ca. ifoxria <br />O <br />covering in accordance with the terms thereof, of the llow inq <br />fo facet, °n(s � <br />INSURED LIMITS OF LIABILITY <br />HAZARDS C0.CODE POLICY NUMBER POLICY PERIOD Statutory W. C. <br />TYPE OF POLICY One Accident and <br />(a) tandard Workmen's s <br />❑ Aggregate Disease <br />Compensation & <br />Employers' Liability LLB lg 14 62 2/9/79 - 1/1/80 <br />i Each Person <br />(b) General Liability 0 Accident <br />Premises – Operations (including "In- Each ❑ Occurrence <br />cidentol Contracts" as defined below) ❑ S <br />Q $5op,00o, single limit <br />.c Independent Contractors each occurrence- <br />Aggregate – Completed <br />u Completed OPerations /Products i Operations /Products <br />m L ❑ ._ - - -- — — <br />Contractual, (Specific type as X — _ _ _ _ _ - -- ` � Accident <br />_described in footnote below) _ _ — Eoch jl C] occurrence <br />Premises – Operations (Including ❑ E <br />fin <br />"Incidental Contracts" as deed x Included <br />• below) Aggregate – Pre- . /Oper. <br />°p El S Aggregate– Protective <br />Independent Contractors Aggregate– Completed <br />e❑ $ Operations /Products <br />o Completed operations /Products i Aggregate– Contractual <br />a` <br />Contractual, (Specific fYPe as O El <br />described in footnote below Each Person <br />(c) Automobile Liability $ <br />Accident <br />„ Owned Automobiles Each ❑ Occurrence <br />v Hired Automobiles -- <br />m — <br />Non _ ow'ned Automobiles 0 Accident <br />Each Q <br />occurrence <br />`• S <br />is E Owned Automobiles <br />0 o Hired Automobiles <br />ao ... <br />Subject all the policy terms applicable, specific can - <br />Contractual Footnote: I <br />era dual coverage is provided as respects <br />Check \❑ ° contract <br />APPlicahle/1�� purchase order agreements between the Insured and <br />Block all contracts <br />NPME OF OTHER PARTY <br />It is the intention of the com an 'ho"" thOevCOYlL37,ks4f <br />OT iclieSethe company, the�l`PPP"'f� <br />cellation of the policy /or pro ides y <br />days' written notice of such cancellation will be given to <br />you at the address stated above. <br />T <br />RACT NO OF ANY <br />easement agreement, sxce t in c nett ion wi censhucti on or demolition oper, <br />Definitions: "Incidental contract" means any riven (1) <br />lease of premises (2) fan , in co ne or oe with work n <br />tions on or adjacent to a railroad, (3) undertaking to indemnify a municipality greem rsauired by m iup or <br />the municipality, (4) <br />sidetrack agreement, or (5)elevator maintenance agreement. orized Representative <br />LC�i3sgC PTO. IN U -5. A. a ORIGINAL <br />