HomeMy WebLinkAboutBOND LOGISTIX, LLC 4-2009iNSURf;IVGL ON FILE
'7';ORK MAY PROCEED
UNTI! INSURANCE EXPIRES
10-01-D~l
CLERK OF COUNCIL
DATE:3_~_Oy
AGREEMENT FOR EXAMINATION SERVICES
N-2009-015
(1, ~~ ~~nanCL
~~ck lam
THIS AGREEMENT is entered into as of March 2, 2009, by and between the CITY OF
SANTA ANA (the "Issuer") and BOND LOGISTIX LLC ("BLX"), as follows:
Recitals
A. The Issuer has been notified by the Internal Revenue Service (the "IRS") that its
Certificates of Participation (Santa Ana Recycling Project), 1996 Series A (the "Bonds"), which
were issued by the Issuer in the principal amount of $11,990,000, are the subject of an
examination by the IRS (the "IRS Examination").
B. The Issuer desires to engage the services of ORRICK, HERRINGTON &
SUTCLIFFE LLP ("Orrick") through BLX for special tax counsel services to represent it in
connection with the IRS Examination of the Bonds.
C. The Issuer has determined that BLX and Orrick possess the necessary
professional capabilities and resources to provide the services required by the Issuer in
connection with the IRS Examination and as described in this Agreement.
Agreement
1. Scone of Services To Be Provided by BLX. Subject to any exclusions as set forth
below, BLX shall, with the assistance of Orrick as appropriate, perform the following services:
(a) BLX shall appoint Omek to act as the primary contact with the IRS Agent
in connection with the IRS Examination of the Bonds.
(b) BLX, with the assistance of Orrick, as appropriate, shall be responsible
for handling all aspects of the IRS Examination.
2. Scone of Services Not To Be Provided By BLX or Orrick.
(a) Neither BLX nor Orrick is not currently being engaged to provide
disclosure services to the Issuer with respect to disclosure to the "market" as to the status of the
IRS Examination or tentative or final determinations by the IRS with respect to its examination.
(b) The services of BLX and Orrick are limited to those specifically set forth
above. Those services do not include representation of the Issuer in any litigation or other legal,
administrative or legislative proceeding or matter, including without limiting the foregoing, any
other examination, audit or review by any state or federal agency of any other Issuer financing.
The services also do not include any financial advice or analysis.
3. Compensation. In connection with the foregoing, the services will be billed at the
regular hourly rates of BLX and Orrick as established from time to time. The following per
hourly rates currently are currently in effect: $790.00 for Larry D. Sobel; $600.00 for Winnie
Tsien; and $600.00 for Nancy Kummer. Such fees are subject to an adjustment annually.
Fees incurred will be billed in monthly statements which are payable upon
receipt.
4. Termination of Agreement. This Agreement may be terminated at any time by
written notice from either party, with or without cause. In that event, all files of the Issuer
maintained by BLX, shall, at the option of the Issuer, become its property and shall be delivered
to it or to any other party that it may designate; provided that BLX shall have no liability
whatsoever for any subsequent use of such documents. Upon termination, neither BLX nor
Omck shall have any future duty of any kind to or with respect to the IRS Examination
described above.
5. Relationships With Other Parties. The Issuer acknowledges that Orrick regularly
performs legal services for many private and public entities in connection with a wide variety of
matters. For example, Orrick has represented, is representing or may in the future represent
other public entities, underwriters, trustees, rating agencies, insurers, credit enhancement
providers, lenders, contractors, suppliers, financial and other consultant/advisors, accountants,
investment providers brokers, providers brokers of derivative products and others who may have
a role or interest in a financing involving the Issuer or that may be involved with or adverse to
the Issuer in this or some other matter. Given the special, limited role of Orrick as special tax
counsel as described above, the Issuer specifically consents to any and all such relationships.
6. Limitation of Riehts to Parties Successor and Assiens Nothing in this
Agreement, expressed or implied, is intended or shall be construed to give any person other than
the Issuer and BLX any legal or equitable right or claim under or in respect of this Agreement,
and this Agreement shall inure to the sole and exclusive benefit of the Issuer and BLX.
Except as provided herein with respect to the engagement of On•ick, BLX may
not assign its obligations under this Agreement without written consent of the Issuer except to a
successor partnership or corporation to which all or substantially all of the assets and operations
of BLX are transferred. The Issuer shall assign its rights and obligations under this Agreement
to (but only to) any other public entity that issues bonds or delivers certificates of participation
(if not the Issuer), in which case the Issuer hereby acknowledges that any relationship or
obligation of BLX to the Issuer under or by virtue of this Agreement shall be deemed to be
totally annulled ab initio. The Issuer shall not otherwise assign its rights and obligations under
this Agreement without written consent of BLX. All references to BLX and the Issuer in this
Agreement shall be deemed to refer to any such successor of BLX and to any such assignee of
the Issuer and shall bind and inure to the benefit of such successor and assignee whether so
expressed or not.
2
7. Counterparts. This Agreement may be executed in any number of counterparts
and each counterpart shall for all purposes be deemed to be an original, and all such counterparts
shall together constitute but one and the same Agreement.
8. Notices. Any and all notice pertaining to this Agreement shall be sent by U.S.
Postal Service, first class, postage prepaid Co Bond LogistiX LLC at 777 South Figueroa Street,
Suite 3200, Los Angeles, CA 90017, Attention: Nancy Kummer, and to the Issuer at 20 Civic
Center Plaza M25 - 6th Floor, P.O. Box 1988, Santa Ana, CA 92701, Attention: Bich Ta.
The Issuer and BLX have executed this Agreement by their duly authorized
representative as of the date provided above.
ATTEST:
atricia :iealy "
~VClerk of. the Council
CITY OF SANTA ANA
BOND LOGISTIX LLC
w /'~
~
B
~ t Y~l'itM
Y M Af yys~
`i S
,
~
lttle: David N Ram,_~~y Hager
IJ~ ~ _~
FOR APPROVAL:
Francisco Gutierrez
Executive Director - FMSA
APPRO v c,) AS TO FORM
,,~y ;? ,
--6---~_....._..__
Laura Stitt eedy
Assistant City Attorney
By: Nancy Kummer
Title: Managing Director
Fo'm 2848
Power of Attorney
and Declaration of Representative
(Rev, June 2008)
Department of the Treasul)'
IntemalRevenueSsNice
... Type or print. ... See the separate instructions.
OMS No. 1545-0150
For IRS Use Only
Received by:
Name
Telephone
Function
Power of Attorney
Caution: Form 2848 will not be honored for any purpose other than representation before the IRS.
Taxpayer information. Taxpayer(s) must sign and date this form on page 2, line 9.
Taxpayer name(s} and address Social security number(s)
City of Santa Ana
20 Civic Center Plaza M25 - 6th floor
Santa Ana, CA 92701
Date /
Employer identification
number
I
Daytime telephone number
( 714) 647-5434
95: 6000785
Plan number (if applicable)
hereby appoint(s) the following representative(s) as attorney(s)-in-fact:
2 Representative{s} must sign and date this form on page 2, Part J/.
Name and address
CAF No. "'h__"h_?_~QP.-_~?:'!mL____.._____
Telephone No_ ________2J?:_~1;!:_~~~L________
Fax No. ____________?1_3:?_1_2:?_4~_~_____________
Check if new: Address 0 Telephone No. D Fax No. 0
CAF No_ -----------------__________________u____
Telephone No_ ________?_1_?:6_12:2.2!_~__________
Check if ne:~d~~~sdT---T:~~~:1~::~~~D------F~~-NO_ 0
Larry D_ Sobel, Esq.
Orrick, Herrington & Sutcliffe LLP
777 S. FJgueroa St. Suite 3200, Los Angeles, CA 90017
Name and address
Nancy Kummer, Managing Director
Bond LogistlX LLC
777 S. Figueroa St., Suite 3200 Los Angeies, CA 90017
Name and address
CAF No. --..........__.n.h.__.....__.....__..h
Telephone No. ....___...___.....___. h____ _n ___
Check if ne::~~~~s~-[J...--.;:~J-;;Ph~.~~-N.~.-O--....F~.NO. 0
to represent the taxpayer(s) before the Internal Revenue Service for the following tax matters:
3 Tax matters
Type of Tax (Income, Employment, Excise, etc.) Tax Form Number Year(s) or Period(s)
or Civil Penalty (see the instructions for line 3) (1040.941,720, etc_J (see the instructions for line 3)
Arbitrage Rebate B038T 1996 through 2008
4 Specific use not recorded on Centralized Authorization File (CAF). If the power of attorney is for a specific use not recorded on CAF,
check this box. See the instructions for Line 4. Specific Uses Not Recorded on CAF . . . . . . . . . . . . . .... 0
5 Acts authorized. The representatives are authorized to receive and inspect confidential tax information and to perform any and all acts that
I (we) can perform with respect to the tax matters described on line 3. for example, the authority to sign any agreements, consents, or other
documents. The authority does not include the power to receive refund checks (see line 6 below), the power to substitute another representative
or add additional representatives, the power to sign certain returns, or the power to execute a request for disclosure of tax returns or return
information to a third party. See the line 5 instructions for more information.
Exceptions. An unenrolfed return preparer cannot sign any document for a taxpayer and may only represent taxpayers in limited situations.
See Unenrolfed Return Preparer on page 1 of the instructions. An enrolled actuary may only represent taxpayers to the extent provided in
section 1 0.3(d) of Treasury Department Circular No. 230 (Circular 230). An enrolled retirement plan administrator may only represent taxpayers
to the extent provided in section 10.3(e) of Circular 230. See the line 5 instructions for restrictions on tax matters partners. In most cases,
the student practitioner's (levels k and Q authority is limited (for example, they may only practice under the supervision of another practitioner).
List any specific additions or deletions to the acts otherwise authorized in this power of attorney: ........__. ..__ ... ..... ._...._ ... ... ._....
............................--........................-..................................................................._h..._...............
.....................................................................................................................h.........................
.............................-.............................-.................................................h................._...............
6 Receipt of refund checks. If you want to authorize a representative named on line 2 to receive, BUT NOT TO ENDORSE OR CASH, refund
cheeks, initial here and list the name of that representative below.
Name of representative to receive refund check(s) ..
For Privacy Act and Paperwork Reduction Act Notice, see page 4 of the instructions.
Cat. No. 11980J
Fonn 2848 (Rev. 6.2008)
Form 2848 (Rev. 6-2008)
7 Notices and communications. Original notices and other written communications will be sent to you and a copy to the first
representative listed on line 2.
a If you also want the second representative listed to receive a copy of notices and communications, check this box . ... 1ZI
b [f you do not want any notices or communications sent to your representative(s), check this box ... 0
8 Retentionlrevocatlon of prior power(s) of attorney. The fj[jng of this power of attorney automatically revokes all earlier power(s) of
attorney on file with the Internal Revenue Service for the same tax matters and years or periods covered by this document. If you do not
want to revoke a prior power of attorney, check here. ... 0
YOU MUST ATTACH A COPY OF ANY POWER OF ATTORNEY YOU WANT TO REMAIN IN EFFECT.
Page 2
9 Signature of taxpayer(s). If a tax matter concerns a jOint return, both husband and wife must sign if joint representation is requested,
otherwise, see the instructions. [f signed by a corporate officer. partner, guardian, tax matters partner, executor, receiver, administrator. or
trustee on behalf of the taxpayer, I certify that I have the authority to execute this form on behalf of the taxpayer.
~ IF NOT SIGNE AND DATED, THIS POWER OF ATTORNEY WILL BE RETURNED.
Executive Director
Date
Title (if applicable)
Francisco Gutierrez
Print Name
00000
PIN Number
City of Santa Ana
---_.____n____..n____..____...._____._____.__
_n___.__________._____.._______._______._________.._______._______.___
Print name of taxpayer from line 1 if other than individual
-------_______._____u_____n_____________n________________..h_n_u_
Signature
Date
Title (if applicable)
Print Name
00000
PIN Number
----------------------------------------.------
ImII
Declaration of Representative
Caution: Students with a special order to represent faxpayers in qualified Low Income Taxpayer Clinics or the Student Tax Clinic Program (levels
k and I), see the instructions for Part fl.
Under penalties of perjury, J declare that:
. [ am not currently under suspension or disbarment from practice before the Internal Revenue Service;
. I am aware of regulations contained in Circular 230 (31 CFR, Part 10), as amended, concerning the practice of attorneys, certified public
accountants, enrolled agents, enrolled actuaries, and others;
. I am authorized to represent the taxpayer(s) identified in Part I for the tax matter(s) specified there; and
. [ am one of the following:
a Attorney-a member in good standing of the bar of the highest court of the jurisdiction shown below.
b Certified Public Accountant-du[y qualified to practice as a certified public accountant in the jurisdiction shown below.
c Enrolled Agent-enrolJed as an agent under the requirements of Circular 230.
d Officer-a bona fide officer of the taxpayer's organization.
e Full-Time Employee-a full-time employee of the taxpayer.
f Family Member-a member of the taxpayer's immediate family (for example, spouse, parent, child, brother, or sister).
g Enrolled Actuary-enrolled as an actuary by the Joint Board for the Enrollment of Actuaries under 29 U.S.C. 1242 (the authority to
practice before the Internal Revenue Service is limited by section 10.3(d) of Circular 230).
h UnenroJJed Return Preparer-the authority to practice before the Internal Revenue Service is limited by Circular 230, section
10.7(c)(1)(viH). You must have prepared the return in question and the return must be under examination by the IRS. SeeUnenrolled
Return Preparer on page 1 of the instructions.
k Student Attorney-student who receives permission to practice before the [RS by virtue of their status as a Jaw student under section
10.7(d) of Circular 230.
Student CPA-student who receives permission to practice before the IRS by virtue of their status as a CPA student under section
10.7(d) of Circular 230.
r Enrolled Retirement Plan Agent-enrolled as a retirement plan agent under the requirements of Circular 230 (the authority to practice
before the [nternal Revenue Service is limited by section 10.3(e)).
~ IF THIS DECLARATION OF REPRESENTATIVE IS NOT SIGNED AND DATED, THE POWER OF ATTORNEY WILL
BE RETURNED. See the Part II Instructions.
Designation Insert Jurisdiction (state) or Signature Date
above letter (a-r) identification
a CA
h
Form 2848 (Rev. 6-2008)
ACORD~
1"1./
L.UOb' -()?r5
'/
PRODUCER
MARSH RISK & INSURANCE SERVICES
1 CALIFORNIA STREET
CALIFORNIA LICENSE NO. 0437153
SAN FRANCISCO, CA 94111
AlIn: Audrey Se9alld (415)743-8632
19025.BOND-MM-08_09
CERTIFICATE OF LIABILITY INSURANCE
r,^,t.\f.l:,";n'n"
1 O'G:l120011
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATlOr
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OF
ALTER THE COVERAGE AFFORDED BY THE POUCIES BELOW.
BOND LOGISTIX LLC
FUND SERVICES ADVISORS, INC.
777 SOUTH FIGUEROA STREET, SUITE 3200
LOS ANGELES, CA 90017
I
INSURERS AFFORDING COVERAGE _ _: NAlC!'
'NSURER A: Twin City Fire Insurance C!' ~9459
INSURERS: Hartford Underwrilers Insurance Company ,30104
II'NNSSUURREERR.O C',: -~-=-~~-'_- ~ ~ I
--- ----L
I'N5URERi
NSURED
:OVERAGES' '- - _'_ __ __ _ __ _ -,-
-THE POLlC'IES OFINSURANCE LISTED BELOW' 'HAVE BEEN ISSUED TO THE INSURED NAMED ABoVE FOR THE POliCY PERIODIND/CA TED,
NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOcUMENT WITH RESPECT TO WHICH THIS CERTIFICATE
MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND
CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
~::~~ TYPE~~~ ,- POllCVN~"'~-~A~~:~~~~~="- - LIMITS
;GEN R ... EA~C RENe ._L
- rDAIAAGE TO RENTED
L I CO~lMERCIAl GENERAL LIABILITY PREMISESlEo """',,",co, $ _ _
~ . ' ClAIMS MADE r --' OCCUR M~ '^'" ""0 ..""n) S _
' -- . - - - - PERSONAl & AOV INJURY $
L.l_ - - - GENE_AGGReGATE 1$ ---
~ENERALAGGREGAr~,\'~IT APPLIES PER ~ROOUCTS'COMPIOP~
i POLlCY JECT I LOC
I AUTOMOBILE UABlUTY
n ANY AUTO
BALL OWNED AUTOS
. SCHEDULED AUTOS
HIRED AUTOS
NON-OWNEO AUTOS
COMBINED SINGLE LIMIT $
(E4:l ncetdenl)
r OOOlLYINJURY ~
(Perpen;on)
GARAGE UAEaUTY
'---;
J ANY AUTO
EXCESSIUMBREUA UABlUTY
""-'-'-'1 OCCUR ~ I CLAIMS MADE
' L_
l DEDUCTIBLE
BOOll Y INJURY
(Per accident)
----..--.
PROPERTY DAMAGE
(Petaccidcnl)
$
$
RETENTION $
WORKERS COMPENSATlON AND
EMPLOYERS' UABlUTY
ANY PROPRIETORIPARTNERiEXECUTIVE
OFFICEAA.EMBER EXCLUDED?
,
, If Vl!'S, de5Cribe under
i SPECIAL PROVISIONS below
OTHER
AGG
~. .._ H OCCU~r:tENCE
AGGREGATE
~~_.- -
.~--
AUTO ONLY -EA ACCIDENT i$
EAACC S-
aTHER THAN
AUTO ONLY; S
$
$
$
$
57 WE TU9541 (ADS)
57 WE TU9541 (TX)
10101108
10101/08
10/01/09
10101109
x
OTH-
.L EACH ACCIDENT $
.L DISEASE. EA EMPLOY $
--
.L DlSEASE . POLICY UMlT $
""1;000,001
-.'-
1.000,001
1,000,00(
SCRIPTION OF OPERATlONSlLDCATlONSNEHtcLES/EXCWSIONS ADOED BY ENOORSEMENT/SPE:CIAl. PROVISIONS
idence of Workers' Compensation coverage.
APPRO ED AS TO FORM
"-
Laura Stitt Sheedy
Assistant City Attorney
:RTIFICATE HOLDER
SEA-001249344-o2
CANCElLATION
City of Sonia Ana ./..; ./
Altn: Bich Ta X 5 't-. .,.
20 Civic Center Plaza M-17
Santa Ana, CA 92701
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCEUED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER wru ENDEAVOR TO MAlL
~ DAVS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMfO TO THE LEFT,
BUT FAILURE TO DO SO SHAlL lro1POSE NO OBLIGATION OR: LIABILITY OF ANY KIND
UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES,
A~T~~i~'1~~~T~ervsetlVices .~
Gene WiJlinms
ORD 25 (2001/08)
,~ ^f"ADn "'1"'\n:no""lM~T'''''''' .....""
' CERTIFICATE OF INSURANCE ISSUEDAT'E:
~;~;,>;~p® 2/5/2010
~ _ ___ _ __
I'R..~I l.'~ Ia:: 'T'HIS CERTIFICATF. IS ISSUED AS A MATTER OF INFORMATION ONLY AND
CONFERS NO I21GH'fS UPON THE CERTIFICATE HOLDER, 'THIS CERTIFICATE
``~1'~ iIS Fargo Insurance Services USA
IriC. DOES NOT AMEND, EXTEND OR ALTL'R OTHER COVERAGE AFFORDED BY'CHE
, POLICIES BELOW.
~; ~ I'1'('mOnt Street, SUlte 800 COMPANIES AFFORDING COVERAGE
S~: r, I' 1 ~1nC1SC0 CA 94105 coMPANY
'
'
Great Northern Insurance Company
LE
I7
ER A
C'A DOI License #OD08408 con1PANY
Federal Insurance Com an
P Y
~_ _ _^_ LETTER B
i ~d~:Ui l-D COMPANY
dL
S
i
ti
LLC LETTER C
or~
x,
og
s conTPANY
,,,,-mouth Figueroa Street, Ste. 3200 LE'rreRD
i-~ s :~ngeles
CA 90017 a>MPANY
, LETTER F.
___~_ _
COVERAGES AND LIMITS
_
"i'HEl 1S ICI CHI2'I'IFY T'ILAT THE POLICIES OF INSURANCE LLSTED BET.OW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,
~:O'14N Ill IS'I',AADING ANY REQUIREMENT, TERM OR CONDTTION OF P.NY CONTR 4C T OR OTHER DOCUMENT W ITH RESPFC'T TO WHICH THIS CERTiF*CnTr. M11AV BF. IgsLJFn nR MAv'
I'GI:IAI\. "I'I-I P: INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 15 SU BJECT TO ALL THE TERMS, EXCLUSIONS AND CONDTTIONS OF SUCH POLICIES. i1MITS SI101NN
iA1Al' I-1,A1 F RELN RFDUCL•D BY PAID CLAIMS.
CCU. 'I'YPI: OP INSURANCE POLICY NUMBER POLICY EFF. POLICY EXP. DESCRIPTION LIMITS
Cl'I< DATE DATE
GCNP:KALLL~BILH'Y GENERAL AGGREGATE $ 2,000,000
;~ r~ C'O\-Ir,t. GENERAL LIAB.
1_-- 3582-11-51 02/01/10 02/01/11 PROD-COMP/OP AGG. $ SUh)eCt t0 the
General
Aggregate
f'~ C I_r\I\iS MADE PERS dr ADV. EvJIIRY' $ 1,000,000
i I ~ I C~CCCRREVCF
LJ EACHOCCL'RRENCE $
1,000,000
IL_-~ ~hY \'I':R'S ~ CONT'RACT'S PROT FIRE DAMAGE (One Fire) ~ $ 1,000,000
F--- MEDICAL EXPENSE (One Per) $ 10,000
AUTOAIORILE LIABIL71'Y
L~ A~\Y AUTO 7499-6569 02/01/10 02/01/11 COMBINED SINGLELIMI'T $ 1,OOQ000
I ~ l-~ ALL 011~NED AUTOS
l BODILY INJURY (Per Person) $
~
~ SLI I LI)ULED AUTOS BODILY INJURY (Per Accident) $
L~ I IIRIiD AUTOS PROPERTY DAMAGE $
CJ NON-OWNED AUTOS
~ ~ CrARAGE LIABILITY
I
l_ _~
12 DSCI'.S I L1GIl,IT1' EACH C~CURRENCE $ 5,000,000
j
~, ~ UvIPIfIiLL.A FORM 7982-0023 02/01/10 02/01/11 AGGREGATE $ 5,000,000
_
-
'
__-
~
:J fl ii'.It
fti:\N UMBRELLA FORM
- --
._ .
;
l1~ORKERS' COMPENSATION ^ STATUTORY LTR%11FS'' `
AND ~~I~1)t~_{..~~L3~ ;'~...T ,1 1~3 1 L)I\.i~/I EACH ACCIDENT
.~
RA1PLOYE R'S LIABILITY ~ DISEASE- POLICY LIMIT ~
r ~ DISEASE -EACH EMPLOYEE _
?1'111 R I`~til'P.ANCE _ ~. _ ~--..,...~__.__
_ __ /
llLSCRIPTIONOFOPERATIONS/LOCATIONS/VEHICLES/SPE IA LITEMS: "
!~he Cite. its oilicers, agents, volunteers and employees are nam ed as Additional Insured. ~ - ~ `~
t,rt
'~.':1 X11 AN D ADDRESS OF CERTIFICATE HOLDER: CANCELLATION:
SHOULD ANY OF THF. ABOVE DESCRIBED YOLICIES BE CANCELED BEFORE THE EXI'IR.4'I']ON
DATE "THEREOF, THF. ISSUING COMPANY WILL ENDEAVOR TO M.41L 30 DAYS WRff"I'tiN
C.l ly Ol 5antd And, FFrldnce dnd Management NOTICE TO THE CER"CIFICAI'E HOLDER NAMED TO THF. LEFT, BLT FAILURE 7'O MAIL SUCH
'
'
C,
1 1' I
C
C'S A NO
T
ICE SHALL IAIPC~E NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY,
.
.
gency
C ITS AGENTS OR REPRF•.SENTATIVES.
20 Civic Center Plaza M17
P.O. 13ox 1988
~~/
~~
~nta Ana, CA 92701 /
p ~ ~i~
~\,tn: Francisco Gutierrez ~ r¢ ,g „~
:A~orcl 25-S (7/97) ACORD CORPORATION 1988
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on
tt2~~s certificate does not confer the rights to the certificate holder in lieu of such endorsement (s).
C ~' SU i3i20GATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may
rc~tu~zr an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu
ul';;i:ch endorsement (s).
DISCLAIMER
"i'he =_'crtificate of Insurance on the reverse side of this form does not constitute a contract between the issuing
insurer (s), authorized representative or producer, and the certificate holder, nor does it affirmatively or
~~cti~titivt~ly amend, extend or alter the coverage afforded by the policies listed thereon.
a
° CERTIFICATE OF LI °
°"""
v
ABILITY INSURANCE tTm"
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMENO, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSUREIRS), AUTHORI7ED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER,
IMPORTANT: H the cedMCete holder Is an ADDITIONAL INSURED, the pollry'les) must be endorsed, N SUBROGATION IS WAIVED, eubjedM
the terns and CORI OF the polity, Certain policies may require an endwaemerA A MNIBment DO this aHMGate does not Colder rlghb to the
Ceflift holder in Has of RICH endonemerls).
PRODUCER CONTACT
RARSH RSXdINSURANCE SERVICES NAME,
95 CALIFORNIA STREET
SUIETMO PROs Pus
, N Ac NA
CALIFORNIA LICENSE N0,G4171M I
_
SAN FRANCISCO
CA 9104 mDPteM
,
IMeu LSAFPORMROCON kOE Rocs
IW5S}BLY4EdU1117 _ MRMA; XLSgMaNylowrmmCDmpey 7M8S
INWRFO
'
EXEROUPUC ASCII
MSOUTH FIGUERQASIREEI,SUITE YW M9URENC,
LOSANGOES, C4 XG17
INCURRED:
NRIRENE,
INSURER F, - -
COVERAGES CERTIFICATE NUMBER: SFAm19:6115.14 REVISION NUMBER:?
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOOIMENT WITH RESPECT TO WHICH THIS
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