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ACC> DATE {MMIDDfYYYY}
<br />,,.. CERTIFICATE OF LIABILITY INSURANCE 1 1017/2015
<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 endorsement(s).
<br />PRODUCER,
<br />Arthur J. Gallagher & Co.
<br />Insurance Brokers of CA. Inc. LIC # 0726293
<br />505 N Brand Blvd, Suite 600
<br />Glendale CA 91203
<br />INSURED
<br />Orange County Conservation Corps
<br />1853 N. Raymond Ave.
<br />Anaheim, CA 92.801
<br />Annie Lee
<br />., ........
<br />818-539-2300
<br />,nnie Lee aaaia.com
<br />MAIC #
<br />INonProfits United
<br />Great American Insurance Compa>� 16691
<br />.._ ...._-...- ..
<br />:Great American Alliance Insurance C 2683;
<br />:Hanover Insurance ComDarly 722(),
<br />r`r1'l/OriA P -GC. r1r- !"r'ICHIAI`C til IRMOC:D. '1A,.,tl9r"i QFi1 war kllctnkr Mv,. nxxn�n.
<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 />INSR POLICY EFF POLICY EXP:._ -�. .-.........�.
<br />LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMlOOPYYYY) LIMITS
<br />B X
<br />.............
<br />COMMERCIAL GENERAL LIABILITY
<br />.
<br />Y
<br />PAC5603794 10/112015
<br />_iMMIDOrgy-YI
<br />101112016
<br />EACH OCCURRENCE.
<br />$1„000,000
<br />CLAIMS -MADE EJ OCCUR
<br />DAMAGE Tb REN EEO ....--....._
<br />............--
<br />.
<br />PREMISES Ea occurrence
<br />MED EXP (Any one person)
<br />5100,000
<br />$5,000
<br />X
<br />Prof $1MM/$3MM
<br />PERSONAL & ADV IN,IURY
<br />$1,000,000
<br />GENT AGGREGATE LIMIT APPLIES PER:
<br />GENERAL AGGREGATE.
<br />$2,000,000
<br />PRO-
<br />.._.... .......
<br />..._
<br />POLICY JECT . LOC
<br />PRODUCTS - COMPIOPAGG
<br />$1,000,000._
<br />OTHER.:
<br />S
<br />B
<br />AUTOMOBILE
<br />X...,
<br />LIABILITY
<br />ANY ALTO
<br />CAP0991249
<br />101112015
<br />10/1/2016
<br />CQMBODILY INJURY$1,000,000
<br />Ea aBINE l),.,_,_
<br />BODILY (Per person)
<br />5
<br />ALL OWNED AUTOS
<br />AUTOS AUTOS
<br />BODILY INJURY Per accident
<br />( )
<br />5
<br />X
<br />NON -OWNED
<br />HIREDAUTOS X AUTOS
<br />PROPERTY DAMAGE
<br />Pet accident
<br />5
<br />X
<br />Comp $100 X Call $500
<br />C
<br />X
<br />UMBRELLA LIAB OCCUR
<br />UMB 5603795
<br />10/112015
<br />101112016
<br />EACH OCCURRENCE
<br />L $2,000,000
<br />AGGREGATE
<br />$2,000000
<br />IDECESSLIARETENTIONSCLAI�MS-MADE
<br />E�l
<br />10,000
<br />$
<br />A
<br />WORKERS COMPENSATION
<br />NPU-WCG001-2015
<br />1/1%2015 111/2016PER
<br />(}TB.i_ -
<br />'�` TAT
<br />AND EMPLOYERS' LIABWLITY Y f N
<br />_L ER
<br />- ............ — ----
<br />ANYPROPRIETOWPARTNERIEXECUTIVE
<br />OFFICERIMEMBER EXCLUDED?
<br />N!A
<br />E -L EACH ACCIDENT $1,000000
<br />....._-.-
<br />{Mandatory in NH)
<br />E.L. DISEASE EA EMPLOYEE
<br />IIe5, dBSCfIl7e under
<br />�'
<br />- $1,000,D00
<br />.... ,,,,_ ...._....... �.............
<br />DESCRIPTION OF OPERATIONS below
<br />E.L. DISEASE - POLICY LIMIT $1,000,000
<br />D
<br />Directors & Officers
<br />LH3 9817317 03
<br />10/112015
<br />D11/2016 Each Claim $2,060,000
<br />DESCRIPTION OF OPERATIONS! LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is requ'trod)
<br />The City of Santa Ana, its officers, agents, employees and volunteers, and the State of California, its officers, employees, and volunteers are
<br />named additional insured/Funding Source with respect to the operations of the named insured per the attached CG 2026 endarsymetlt. Such
<br />insurance is Primary and Non -Contributory. Workers Compensation coverage excluded, evidence only.
<br />h
<br />CERTIFICATE HOLDER CANCELLATION
<br />City of Santa Ana, Workforce Investment Board
<br />1000 E. Santa Ana Blvd., Ste. 200
<br />Santa Ana CA 92701 USA
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />THE, EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />AUTHORIZED REPRESENTATIVE
<br />1986-2014 ACORD CORPORATION. Ali (rights reserved.
<br />ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
<br />
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