2018/05/08 Shott, Elizabeth & Mc Gregor, Lois dba McGregor Shott Certificate of Liability Insurance (5) l�` !7 O CERTIFICATE OF LIABILITY INSURANCE 09/1919® DATE( / Y)
A
vO,A /20182018
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 CONTACT DARIN TSUKASHIMA,AGENT
DARIN TSUKASHIMA NAME:
STATE FARM INSURANCE E-MAIL PHM
t 661-260-1400 ac No:661-260-2787
ADDRESS:CAROL@DARINTSUKASHIMA.COM
O26650 THE OLD ROAD SUITE 205 PRODUCER CUSTOM 75-1297
t VALENCIA CA. 91381 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A:State Farm Fire and Casualty Company 25143
SHOTT, ELIZABETH 8r MC GREGOR, INSURER B:State Farm Mutual Automobile Insurance Company 2517E
LOIS DBA MCGREGOR SHOTT INSURER C:State Farm General Insurance Company 25151
24325 MAIN ST STE 101 INSURER D:
NEWHALL, CA 91321 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 ADDL SUER POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MM/DD MMIDD/YYYY LIMITS
A GENERAL LIABILITY 92-C3-P096-8 G 09/12/2018 09/12/2019 EACH OCCURRENCE S 1,000,000
X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence S
CLAIMS-MADE OCCUR ❑❑ MED EXP(Any one person) S 5,000
PERSONAL&ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000
X POLICY PE LOG S
B AUTOMOBILE LIABILITY P17 6547-E08-75K 05108/2018 OS/08/2019 COMBINED SINGLE LIMIT S 1,000,000
(Ea accident)
ANY AUTO ❑❑ 10 HONDA CRV BODILY INJURY(Per person) S
ALL OWNED AUTOS VIN# BODILY INJURY(Per accident) 5
X SCHEDULED AUTOS JHLRE3H75AC005497 PROPERTY DAMAGE $
HIRED AUTOS (Per accident)
NON-OWNED AUTOS COMP DEDUCTIBLE $ 250
COLL DEDUCTIBLE $ 250
UMBRELLA LAB OCCUR EACH OCCURRENCE 5
EXCESS LIAB CLAIMS-MADE❑❑ AGGREGATE S
DEDUCTIBLE $
RETENTION S $
WORKERS COMPENSATION WC STATU- OTH-
AND EMPLOYERS'LIABILITY Y/N TORY LIMITS ER
ANY PROPRIETOR/PARTNER/EXECUTIVE❑ ❑NIA A E.L.EACH ACCIDENT S
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH) E.L.DISEASE-EA EMPLOYE 5
I yes,describe under
E.L.DISEASE-POLICY LIMIT I S
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required)
FY18/19 ON CALL MARKETING&DESIGN SERVICES
CERTIFICATE HOLDER CANCELLATION
City of Menifee SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
29714 Haun Road EXPIRATION DATE HEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE
POLICY Menifee,CA 92586
AUTHORIZED REPRESENTATIVE
CAROL CLARKE
@ 1988-2009 ACORD CORPORATION. All rights reserved.
ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD 1001486 132849.4 02-11-2010