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S.F. FORM <br />CERTIFICATE OF INSURANCE <br />FORM <br />(Oct. 196 <br />Certificate issued to <br />lame and address of Insured <br />C't of Santa Ana <br />Saddleback Inn, Santa <br />Ana <br />c/o City Attorney <br />1650 E. Fir St.- <br />Civic i Center, <br />Santa Ana, Ca.. <br />a.nta. Aria, Ca, <br />Perils insured against <br />deductible, applying to <br />Fire and Lightning ❑ Sprinkler Leakage <br />❑ Extended Coverage❑ <br />❑ vandalism & Malicious Mischief ❑ <br />Location of property covered <br />1 Covering Pedestrian bridge at Saddleback <br />Inn, <br />{2 ) SSanta Ana, Ca . <br />Policy <br />Insurer <br />Tern <br />Coverage & <br />Amount of <br />Number <br />From To <br />Locations <br />Insurance <br />C0016412 <br />Fremon end . ins <br />11/2 -- 77 <br />BI—PD <br />1, o 0 0, o 0 0. <br />Legend: <br />SP - Specific insurance B - Building 1-Location <br />1 <br />BL—Blanket insurance BE —Building(s) & Equipment 2—Location <br />#2 <br />— Reporting forte—a.mount of ins. E —Equipment 3—Location <br />#8 <br />shown is limit of liability for all ES —Equipment & Stock 4—Location <br />contributing insurance S —Stock .—All <br />locations <br />❑ Mortgagee Clause (requires 10 day writte n notice of cancellation to mortgagee) <br />El Lenders Loss Payable Endorsement (policy continues in force 10 days after written notice of <br />cancellation is received by lender) <br />❑ Other payee clause (copy attached to this Certificate) <br />Policies contain clause indicated above. Loss, -if any, payable to the party to whom this Certificate <br />is issued, unless otherwise noted below. <br />I certify that the above described policies exist and cover only in accordance with the policy terms. 4=1 <br />( I NA`F'URE) t��7� } � JXYA1r Eb <br />offer L . Rohrer <br />GELKER & ROHRER INS . A'C <br />(FIRM AND ADDRESS) <br />