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OP ID• PC <br />'`�� °� ° CERTIFICATE OF LIABILITY INSURANCE <br />DATE (MM /DD/YYY`n <br />11/08/11 <br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS <br />CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES <br />BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED <br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. <br />IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to <br />the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the <br />certificate holder in lieu of such endomement(s). <br />PRODUCER 626 - 405 -8031 <br />Chapman <br />License #0522024 626 05 -0585 <br />P. O. BOX 5455 <br />Pasadena, CA 91117 -0455 <br />_ <br />CONTACT <br />NAME: <br />_ <br />PHONE FAX <br />Maw E : _ F. No): <br />ADDRESS: <br />PRODUCER gAC KT -1 <br />CUSTOMER ID #: <br />INSURERS AFFORDING COVERAGE <br />NAIC # <br />INSURED Back to Natives Restoration <br />PO Box 6539 <br />Irvine, CA 92612 -6539 <br />INSURER A: New York Marine and General <br />INSURER B : <br />INSURER C <br />$ <br />INSURER O <br />$ <br />INSURER E, <br />$ <br />INSURER F; <br />$ <br />COVERAGES CERTIFICATE NIIMRFR• RFV141(lN wIMRFR• <br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD <br />INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS <br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, <br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br />ILTR T <br />TYPE OF INSURANCE P <br />POLICY NUMBER M <br />POLICY EFF P <br />POLICY EXP <br />LIMITS <br />GENERAL LIABILITY E <br />C t� <br />EACH OCCURRENCE $ <br />$ <br />T'(E,— T <br />urre <br />PREMISES cnce $ <br />$ <br />MED EXP (Any one person) $ <br />$ <br />PERSONAL 8 ADV INJURY $ <br />$ <br />GENERAL AGGREGATE $ <br />GEN'L AGGREGATE L <br />LIMIT APPLIES PER: P <br />PRODUCTS - COMP /OP AGG $ <br />AUTOMOBILE L <br />LIABILITY C <br />^A` »y �L,C � <br />5t]�%� B <br />B <br />COMBINED SINGLE LIMIT $ <br />$ <br />BODILY INJURY (Per person) $ <br />$ <br />BODILY INJURY (Per accident) $ <br />(Par ODAMAGE $ <br />$ <br />$ <br />UMBRELLA LU\B O <br />OCCUR E <br />EACH OCCURRENCE $ <br />$ _ <br />AGGREGATE $ <br />_ <br />DEDUCTIBLE $ <br />$ <br />$ <br />A A <br />WORKERS COMPENSATION X <br />NIA <br />( <br />WC201100000404 1 <br />10/26111 1 <br />10126/12 E <br />X WC STATU- OT- <br />E.L. EACH ACCIDENT $ <br />$ 1,000,000 <br />E.L. DISEASE - EA EMPLOYE $ <br />$ 1000000 <br />E.L. DISEASE - POLICY LIMIT $ <br />- <br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101• Additlonal Remarks Schedule, if more space is required) <br />Re: Application Fee # 20100119693 <br />Sacramento, CA 95826 /. —V�-' <br />© 1988 -2009 ACORD CORPORATION. All rights reserved_ <br />ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD <br />