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Insurance - Mejorando Group - 2012-26-12 MEJOR-1 OP ID: EP AACCXR® DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 12/26/12 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 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 8100 COMA CT Bollinger,Inc. U t C I I 3- 3-3663 PHONE FAX 232 Strawbridge Drive (A/C,No,Ext): (NC,No): Moorestown,NJ 08057-4604 E-MAIL Ellen Prusecki JAN 0 7 2013 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Ii 't I ! I !a INSURER A:United States Liability Ins Co 25895 INSURED The Mejorando Group - - - ' INSURER B: 7409 North 84th Avenue Glendale,AZ 85305 INSURER C INSURER D: INSURER E: INSURER F: 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. INSR TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP LTR INSR WVD I POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY X CX10005131 08/20/12 08/20/13 DAMAGE TO RENTED 50,000 PREMISES(Ea occurrence) $ CLAIMS-MADE X OCCUR MED EXP(Any one person) $ 5,000 Business Owners PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ 2,000,000 GENII AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $ POLICY PRO- JECT I I LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY YIN TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ A Professional E&O CX10005131 08/20/12 08/20/13 ea claim 1,000,000 Claims Made aggregate 2,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Costa Mesa Sanitary District is additional insured with respects to the General Liability as required by written and executed contract. CERTIFICATE HOLDER CANCELLATION \�� 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. 628 W.19th Street u Costa Mesa, CA 92627 �•rt AUTHORIZED REPRESENTATIVE C ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: CX 10005131 BUSINESSOWNERS BP 04 48 07 02 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM SCHEDULE Name of Person Or Organization: Effective Date: 12/26/2012 12:00 AM Costa Mesa Sanitary District 628 W. 19th Street Costa Mesa, CA 92627-2716 *Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The following is added to Paragraph C. Who Is An Insured in Section II - Liability: 4. Any person or organization shown in the Schedule is an insured, but only with respect to liability arising out of your ongoing operations or premises owned by or rented to you. BP 04 48 07 02 ISO Properties,Inc.,2001 Image Manager Page 1 of 1 CERTIFICATE OF INSURANCE SUCH INSURANCE AS RESPECTS THE INTEREST OF THE CERTIFICATE HOLDER NAMED BELOW WILL NOT BE CANCELED OR OTHERWISE TERMINATED WITHOUT GIVING 10 DAYS PRIOR WRITTEN NOTICE TO THE CERTIFICATE HOLDER, BUT IN NO EVENT SHALL THIS CERTIFICATE BE VALID MORE THAN 30 DAYS FROM THE DATE WRITTEN. THIS CERTIFICATE OF INSURANCE DOES NOT CHANGE THE COVERAGE PROVIDED BY ANY POLICY DESCRIBED BELOW. This certifies that: ® STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY of Bloomington,Illinois ❑ STATE FARM FIRE AND CASUALTY COMPANY of Bloomington, Illinois • ❑ STATE FARM COUNTY MUTUAL INSURANCE COMPANY OF TEXAS of Dallas,Texas ❑ STATE FARM INDEMNITY COMPANY of Bloomington, Illinois,or ❑ STATE FARM GUARANTY INSURANCE COMPANY of Bloomington, Illinois has coverage in force for the following Named Insured as shown below: NAMED INSURED: Ibarra, Patrick & Kristin ADDRESS OF NAMED INSURED: 7409 N 84t Ave Glendale, AZ 85305-3900 POLICY NUMBER 066 1485-C22-031 EFFECTIVE DATE OF POLICY 09/22/12-03/22/13 2012 Ford DESCRIPTION OF VEHICLE(including VIN) Expedition dition VIN# 1FMJUIK5OCEF52155 LIABILITY COVERAGE ®YES ❑ NO ❑YES ❑ NO ❑YES ❑ NO ❑YES ❑NO LIMITS OF LIABILITY a.Bodily Injury Each Person $1,000,000 Each Accident $1,000,000 b.Property Damage Each Accident $1,000,000 c.Bodily Injury& Property Damage Single Limit Each Accident PHYSICAL DAMAGE COVERAGES ®YES ❑ NO ❑YES ❑NO ❑YES ❑ NO ❑YES ❑NO a.Comprehensive $ 1,000 Deductible $ Deductible $ Deductible $ Deductible ®YES ❑ NO ❑YES ❑ NO ❑YES ❑ NO ❑YES ❑ NO b.Collision $ 1,000 Deductible $ Deductible $ Deductible $ Deductible EMPLOYERS NON-OWNED CAR LIABILITY COVERAGE Li YES ® NO ❑YES ❑ NO ❑YES ❑ NO ❑YES ❑ NO HIRED CAR LIABILITY COVERAGE El YES ® NO ❑YES ❑ NO ❑YES ❑NO ❑YES ❑NO FLEET-COVERAGE FOR ALL OWNED AND UCENSED MOTOR VE IC ES YES ® NO ❑YES ❑NO ❑YES ❑ NO CI YES ❑NO Agent 1195 12/31/2012 Si we of Authorized Representative Title Agent's Code Number Date ame and Address of Certificate Holder Name and Address of Agent Costa Mesa Sanitary District John C Abercrombie III 628 W. 19th Street State Farm Insurance Costa Mesa, CA 92627-2716 7207 N 7`h St Phoenix AZ 85020 (602) 906-0299 INTERNAL STATE FARM USE ONLY: 0 Request permanent Certificate of Insurance for liability coverage. 122429.3 Rev.07-26-2005 0 Request Certificate Holder to be added as an Additional Insured. https://sfnet.opr.statefarm.org/im_core/jsps/pages/imageManager.faces 12/31/2012