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HUMAOPT-04 ROQCA1
<br />4� ® CERTIFICATE OF LIABILITY INSURANCE
<br />OAT 61/29120162912016
<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(les) 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 License # 0564249
<br />Heffernan Insurance Brokers
<br />6 Hutton Centre Drive, Suite 500
<br />Santa Ana, CA 92707
<br />CONTACT
<br />NAME:
<br />PHONE 1 (774 361.7700 x tg91r{ FAX 1 (714) 361-7701
<br />AIC No Ext: ) AIC No
<br />E-MAIL
<br />ADDRESS:
<br />INSURER(S) AFFORDING COVERAGE NAIC#
<br />INSURERA:Nonprofits Insurance Alliance of California 01184
<br />INSURED
<br />INSURER B: Berkshire Hathaway Homestate Insurance Company 20044
<br />INSURER C:
<br />Human Options
<br />INSURER D:
<br />PO BOX 53745
<br />Irvine, CA 92619
<br />INSURER E,
<br />INSURER F:
<br />COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
<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 SUBJ ECT TO ALL THE TERMS,
<br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
<br />INSR
<br />LTR
<br />rypE OF INSURANCEADDLSUBR
<br />IN5D
<br />WD
<br />POLICY NUMBER
<br />POLICYEFF
<br />MMIODIYYW)
<br />POLICYEXP
<br />(MMIDDNYYYI
<br />LIMITS
<br />A
<br />X COMMERCIAL GENERAL LIABILITY
<br />EACH OCCURRENCE _S110001000
<br />CLAIMS -MADE ® OCCUR
<br />X
<br />201501143NPO
<br />09/23/2015
<br />09/23/2016
<br />PREMISESEeoccurrence $ 500,000
<br />MED EXP (Any one person) $ 20,000
<br />PERSONAL &ADV INJURY $ 1,000,060
<br />GEN'L AGGREGATE LIMIT APPLIES PER
<br />POLICY 7 PRO- ®
<br />ECT LOC
<br />GENERAL AGGREGATE S 3,000,000
<br />PRODUCTS-COMP/OPAGG 5 3,000,000
<br />SEXUAL MISCONDU s 1,000,000
<br />OTHER:
<br />AUTOMOBILE
<br />LIABILITY
<br />COMBINED SINGLE LIMIT g 1,006,000
<br />Ea accident
<br />A
<br />ANY AUTO
<br />201501143NPO
<br />09/2312015
<br />09/2312016
<br />BODILY INJURY (Per person) $
<br />ALL OWNED SCHEDULED
<br />AUTOS AUTOS
<br />BODILY INJURY (Par accident) 5
<br />-PROPERTY
<br />)(
<br />—
<br />NON-OWNEDAUTOS
<br />HIRED AUTOS AUTOS
<br />Per accident 5
<br />5
<br />X
<br />UMBRELLA LIARX
<br />OCCUR
<br />EACH OCCURRENCE $ 5,000,000
<br />AGGREGATE $ 5,000,000
<br />A
<br />E%CESS LIAR
<br />CLAIMS -MADE
<br />201501143UMBNPO
<br />09/23/2015
<br />09/23/2016
<br />DED X RETENTIONS 10,006
<br />$
<br />B
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY
<br />ANY PROPRIETOR/PARTNER/EXECUTIVE YIN
<br />OFFICER/MEMBER EXCLUDED? ®
<br />(Mandatory in NH)
<br />NIA
<br />HUWC703947
<br />04/01/2016
<br />04/01/2017
<br />X PER OTH-
<br />STATUTE ER
<br />E.L. EACH ACCIDENT $ 1,000,000
<br />E.L. DISEASE - EA EMPLOYEE $ 1,000,000
<br />If yes,DESS describe under
<br />DESCRIPTION OF OPERATIONS below
<br />E.L. DISEASE -POLICY LIMIT 1 $ 1,000,000
<br />A
<br />Professional Liabili
<br />201601143NPO
<br />09/23/2015
<br />09/23/2016
<br />Occurrence 1,000,000
<br />A
<br />Sexual Misconduct
<br />201501143NPO
<br />09/23/2015
<br />09/23/2016
<br />Occurrence 1,000,000
<br />DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required)
<br />Re: As per Contract or Agreement on file with Insured. The City of Santa Ana, its officers, employees, agents and volunteers and representatives are included
<br />as an additional insured (and primary) on General Liability policy per the attached endorsement, if required,,.
<br />w1AJ�C r
<br />4 -
<br />CERTIFICATE HOLDER CANCELLATION
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />City of Santa Ana
<br />Community Development Agency
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />20 Civic Center Plaza, M-25
<br />AUTHORIZED REPRESENTATIVE
<br />Santa Ana, CA 92701
<br />1P
<br />© 1988.2014 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
<br />010.
<br />
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