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A► c CERTIFICATE OF' LIABILIITY INSURANCE 10p / (MM/DDYYYY,
<br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATIONONLY 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 INOT 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 />NAMEVy Selfier-Flynn
<br />Wood Gutmann & Bogart
<br />License 0679263
<br />PHONE 714-505-7000 FAX 714 573 1770
<br />(AIC, No, E.xt): (All, me):
<br />15901 Red Hill Ave., Suite 100
<br />E-MAIL W bib.com
<br />ADDRESS: v Y
<br />Tustin CA 02780
<br />INSURER(S) AFFORDING COVERAGE _.. NAIL #
<br />..INSURER'B
<br />INSURER Rhlladelphia Indemnity ins Co, ..__. ._.
<br />INSURED COAST06
<br />:
<br />Coast Live Oak. School
<br />INSURERC: -. ._"... ...
<br />Mark Hay
<br />.... ...._
<br />w' ,-.-
<br />316 Edgewood Read � � M n
<br />INSURER D :
<br />'..Santa Ana CA 92706
<br />INSURER E.: '.
<br />INSURER F :
<br />r`nktI=7A1':.CQ. r`COTICIP A Tr_ All IRAmon. *,)A cif An1Rn nwd rinar,.r.
<br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE
<br />- FOR THE. POLICY PERIOD
<br />INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT
<br />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 _...._ ...TYPE OF IN',...... IADDL SUBR. ......... POLICY EFF
<br />INSURANCE
<br />LTR INSD WVD'.... POLICY NUMBER MMIDD/YYYY
<br />......... ...._...
<br />POLICY EXP
<br />MMlDDNYYY LIMITS
<br />A X ,..COMMERCIAL GENERAL LIABILITY PHPKI531933 9122/2016......
<br />9/22/2017 EACH OCCURRENCE $1,000,000
<br />.. CLAIMS -MADE XODOUR '......
<br />...
<br />DAMAGE TO RENTED....
<br />PREMISES ,(Fa occurrence) $100,000 .........
<br />.. ',.... ',.....
<br />M.,ED EXP (Any one person) $5,000 ....... ..
<br />....... -. '..,
<br />PERSONAL & ADV INJURY $1,000,000
<br />...GENT AGGREGATE LIMIT APPLIES ..PER ''. ',.
<br />GENERAL AGGREGATE.... $2„000,000
<br />X POLICY PRO-
<br />JECT LOC
<br />PRODUCTS $2,00U000
<br />....._ "......
<br />OTHER:.
<br />$ ... .....
<br />AUTOMOBILE LIABILITY
<br />COMBINED SINGLE L $
<br />;._(Ea accident).._. ...........
<br />ANY AUTO tl�
<br />BODILY INJURY (Per person) $
<br />_..
<br />ALL OWNED SCIIC ,
<br />AUTOS AUTOS Y '
<br />BODILY HNJURY (Per accident) $ _. _....
<br />_
<br />NON - OWNED
<br />OWNED "`a'�`y
<br />',... HIRED AUTOS AUTOS '4r
<br />PROPERTYDAMAGE.....
<br />QPrr acc'sdentj $
<br />......... ^^
<br />.
<br />UMBRELLA LIARC7CCURvy11
<br />EACH OCCURRENCE...... $
<br />EXCESS LIA6 CLAIMS -MADE I � � �' `
<br />......... ......._..
<br />i AGGRFGA F $ ........ ...._..
<br />DED RETENTION.£ „�
<br />$
<br />WORKERS COMPENSATION )..
<br />PER OTH
<br />AND EMPLOYERS' LIABILITY YINp
<br />PROP'RIELORIPARTNERIEXECUTIVE
<br />STATUTE _ ERANY'
<br />OFFICERIMEM.BER EXCLUDED? D',, N CA .
<br />E.L. EACH ACCIDENT $
<br />........
<br />(Mandatory in NH)......
<br />E.L.. DISEASE- EA EMPLOYEE'.. $
<br />If yes.., desianbe under
<br />........
<br />DESCRNPTION OF OPERATIONS below ,
<br />E.L. DISEASE - POLICY LIMIT
<br />DESCRIPTION OF OPERATIONS I LOCATIONS! VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached it more space is requiredl
<br />City of Santa Ana, its officers, agents and employees are named as
<br />additional insured on the General
<br />Liability per attached PI GLD VS 01 08. Cancellation verbiage as
<br />per IL0017 11 98 attached. Primary
<br />and Non -Contributory applies on the General Liability per attached
<br />PI GLD VS 01 08..
<br />THIS CERT"IFICAT'E SUPERCEDES ANY PREVIOUSLY ISSUED.
<br />1'-M 1 G RtlLUCr'i.
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />City of Santa Ana; Parks, Recreation and Community THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />Services Agency ACCORDANCE WITH THE POLICY PROVISIONS.
<br />Attn: Carmen Acosta
<br />18255 W. Civic Center Drive
<br />Santa Ana GA 92701 AUTHORIZED REPRESENTATIVE
<br />Q 1988-20114 ACORD CORPORATION, Alt rights reserved.
<br />ACORD 25 (2014/01) The ACORD name and logo are registered marks Of ACORD
<br />
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