Insurance - Lakewood Alarm - 2023-12-07ACC?RC) CERTIFICATE OF LIABILITY INSURANCE
DATE(MMIDDIYYYY)
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
12107!2023
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 AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER
CONTACT DONNA _ .... ......... --..
$ c3r�$�dtttl JIM CONRAD
-NAME .. __
FAX
HONo..Extl_562-598-2415 562-431 4410
1066 BOLSA AVENUE
—
E-MADD Ems, donna. m._re_geon.jwls statefarm.com
SEAL BEACH, CA 90740
INSURES AFFORDING COVERAGE NAIc >k
INSURER A: State Farm Mutual Automobile Insurance Compan 25178
INSURED
INSURER B:
DAMAGE TO RENTED
LAKEWOOD ALARM
INSURER C
1530 CONSUMER CIRCLE, STE 102
INSURER D:
INSURER E
CORONA, CA 92880
INSURER F:
_CtENI,rtE� (E�.9sa5lfSaAC67__.
$ _........._.............
COVERAGES CERTIFICATE NUMBER: 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 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSRB ----- POOUC TCY-EXP ..._ - -- �__..... .. ...... V—
LTR TYPE OF INSURANCE D WVD POLICY NUMBER MMIDDlYYYY MMIDDIYYYY
MD
290 PAULARINO AVE 0 . qgIg"i
AU
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
$
DAMAGE TO RENTED
CLAIMS -MADE t �i OCCUR
..
_CtENI,rtE� (E�.9sa5lfSaAC67__.
$ _........._.............
MED EXP (Any one person)
$
PERSONAL & ADV INJURY
_. ___ _...--_._--_.
$
_
$
GEN'L
AGGREGATE LIMIT APPLIES PER.
GENERAL AGGREGATE
PRO- hj
POLICY JECT I--„ „f LOC
PRODUCTS-COMP/OPAGG
$
$
OTHER:
AUTOMOBILE LIABILITY
$ Ndent)ED INGLE LIMIT
$ 1,000 d00
X ANY AUTO
273 2711-F14-75
112/14/2023
06/14/2024
I BODILY INJURY (Per person}
$
A
OWNEDSCHEDULED
ONLY !h AUTOS
y430
BODILY INJURY (Per accident)
l $
HIRED
8026-628-75
08/28!2023
02/28/2024
XAUTOS
AUTOS ONLY AUTOS ONLNON-OWNEY
Pe ccitlen _ _ 4
$-
$
UMBRELLA LAB OCCUR
'
EACH OCCURRENCE
$
EXCESS LIAR CLAIMS -MADE
_. -_ .._...�. ......
AGGREGATE
_....._..._. .__ ...._........._
$
_... _._..---`. ._..
DED RETENTION $
S
WORKERS COMPENSATION
I PER OTH-
E
$
AND EMPLOYERS' LIABILITY
ANY PROPRIETORIPARTNEWEXECUTIVE Y / N
OFFICER/MEMBER EXCLUDED?
N 1 A
E.L. EACH ACCIDENT
__ .........._
$ _... _. .....--...
(Mandatory in NH)
E.L.DISEASE - EA EMPLOYE
_._.._ ,__._.. -P-
'ye
$
If yes, describe under
DESCRIPTION OF OPERATIONS below
EL. DISEASE - POLICY LIMIT
$
i
I
j
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
ALL OPERATIONS: COSTA MESA SANITARY DISTRICT, THEIR ELECTED AND APPOINTED OFFICIALS, AGENTS, OFFICERS, VOLUNTEERS, AND
EMPLOYEES LISTED AS ADDITIONAL INSURED PURSUANT TO ATTACHED ENDORSEMENT
CERTIFICATE HOLDER CANCELLATION
O 1988-2015 ACOtD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
1001486 132849.14 04-13-2022
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
COSTA MESA SANITARY DISTRICT
ACCORDANCE WITH THE POLICY PROVISIONS.
290 PAULARINO AVE 0 . qgIg"i
AU
COSTA MESA, CA 92626
O 1988-2015 ACOtD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
1001486 132849.14 04-13-2022