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OCCUM-1 OP ID. AM
<br />CERTIFICATE OF LIABILITY INSURANCE
<br />DATE 0811012016 811 01 2 01 6 Y)
<br />Q$11QI2016
<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 />REPRESENTATWE OR PRODUCER, AND THE CERTIFICATE HOLDER.
<br />IMPORTANT: If the Certificate holder Is an ADDITIONAL. INSURED, the pollcy(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 />One Source Health & Wealth Mgt
<br />410 West Fallbrook Avenue #202
<br />Fresno, CA 93711
<br />Tony Stornetta
<br />REACT Tony Stornetta
<br />PHONE 55g_492-1361 FAX No :559-354 0190
<br />Arc No Ext
<br />RnnREss: Tony@healthwealthadviso!y.com
<br />ENSURER S AFFORDING COVERAGE NA€C A
<br />INSURERA: Hartford Casualty Insurance Co 29424
<br />INSURED Occu-Med, LTD
<br />INSURER B: CNA
<br />2121 W Bullard
<br />Fresno, CA 93711
<br />1NSaRERC;
<br />CLAIMS -MADE 0 OCCUR
<br />INSURER D:
<br />INSURERE'.
<br />57SBAID4587
<br />INSURER F :
<br />08/1312017
<br />11-nVFRAr.F1R CERTIFICATE NUMSFR! 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 SUBJECT TO ALL THE TERMS,
<br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
<br />€LFR
<br />TYPE OF INSURANCE
<br />ADO
<br />POLICY NUMBER
<br />POLICY Y
<br />POLICY EXP
<br />LIMITS
<br />A
<br />X COMMERCIAL GENERAL LIABILITY
<br />EACH OCCURRENCE S 2,000,00
<br />CLAIMS -MADE 0 OCCUR
<br />57SBAID4587
<br />08113/2016
<br />08/1312017
<br />pREMISES EaEoccurrenoe S 300,00
<br />MED EXP (Any one person) $ 5,00
<br />EPL
<br />08113/2016
<br />08113/2017
<br />PERSONAL& ADV INJURY $
<br />GML AGGREGATE LIMIT APPLIES PER
<br />GENERAL AGGREGATE $ 4,000,00
<br />POLICY ❑ jRa F—] LOC
<br />PRODUCTS • COMPIOP AGG $ 4,000,00
<br />$
<br />OTHER:
<br />AUTOMOBILE LIABILITY
<br />COMEa accidBINeaent SINGiE LIMIT$
<br />BODILY INJURY (Per persan) $
<br />AANY
<br />AUTO
<br />57SBAID4587
<br />08113/2016
<br />08/13/2017
<br />BODILY INJURY (Per acdderil) $
<br />ALLOWNED SCHEDULED
<br />AUTOS AUTOS
<br />HIREDAUTOS AUTo S
<br />X Hired Car X NonUxned
<br />PROPERTY DAMAGE S
<br />Peraccideat
<br />$
<br />X
<br />UMBRELLALIABOCCUREACH
<br />OCCURRENCE $ 4,000,00
<br />AGGREGATE $ 4,000,00
<br />A
<br />EXCESS LIAe
<br />HCLAJus-h=E
<br />57SBAID4587
<br />08113/2016
<br />08113/2017
<br />DED RETENTION$
<br />S
<br />A
<br />WORKERS COMPE14SATION
<br />AND EMPLOYERV LIABILITY
<br />ANY PROPRIETORIPARTNER✓-EXECUTNE YIN
<br />OFR:ERNEMSEREXCLUDED? Y❑
<br />(Mandatory In NH)
<br />NIA
<br />57WBCZJ9114
<br />0610612016
<br />06/0612017
<br />IPER
<br />X STATUTE O
<br />E.LEACH ACCIDENT $ 1,000,00
<br />E_L DISEASE - EA rMPLOYEE $ 1,000,00
<br />ELDISEASE-POL[CYLIMIT $ 1,000,00
<br />If yyes, desuibe under
<br />DESCRIPn0NOFOPERATIONSbelom
<br />A
<br />Empl Practices Lla
<br />57SBAID4587
<br />08/1312016
<br />0811312017
<br />Aggregate 250,00
<br />B
<br />Professional Llab
<br />25437058
<br />08122/2016
<br />08122/2017
<br />6,000,00
<br />DESCRIPTION OP OPERATIONS I LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is requIred)
<br />Notice of cancellation Is 30 days except in the event of cancellation for
<br />nen-payment or non -reporting which Is 10 days. The City of Santa Ana Its,
<br />officers, agents, volunteers, and employees are added as additional insured
<br />as respects to operations and activities of, or on behalf of the named
<br />Insured performed under contract with the The City of Santa Ana, ,..
<br />SANTAAN
<br />CITY OF SANTA ANA
<br />20 CIVIC CENTER PLAZA
<br />SANTA ANA, CA 92701
<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 />Tony Stornetta
<br />CO 1988-2014 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
<br />
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