2016/07/15 Dino Perugino Certificate of Liability Insurance (3)PERUDI7 OP ID: EF
'4kk � CERTIFICATE OF LIABILITY INSURANCE
DA07/22/2016TE Y)
07/22/2016
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
Supple -Merrill &Driscoll Inc.
Insurance Agents and Brokers
P. 0. Box 2408
Pasadena, CA 91102
CONTACT
Erika Fuentes
PNHME:
FAX
Arc No E,tt :626-795-9921 ac No :626-577-6656
E-MAIL
ADDRESS:
INSURER(S) AFFORDING COVERAGE
NAIC #
Supple -Merrill & Driscoll Inc.
INSURER A: Mercury Insurance Group
11908
INSURED Dino Perugino
702 S. Treanor Ave
INSURERB:
San Dimas, CA 91773-3420
INSURERC:
INSURER D :
INSURER E
INSURER F :
COVERAGES CERTIFICATE NUMBER: RFVISICMI NI IMRFR-
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.
1�TR
TYPE OF INSURANCE
INSD
WVD
POLICY NUMBER
MMIDDY EFF
POLICY EXP
LIMITS
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE OCCUR
EACH OCCURRENCE
$
DA D
PREMISES Ea occurrence
$
MED EXP (Any one person)
$
PERSONAL & ADV INJURY
$
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY PRO ❑
JECT LOC
OTHER:
GENERAL AGGREGATE
$
PRODUCTS - COMP/OP AGG
$
$
A
AUTOMOBILE
LIABILITY
ANY AUTO
ALL SCHED
AUTOS�ED X AUTOSULED
NON -OWNED
HIREDAUTOS AUTOS
040104120149615
07/15/2016
01/15/2017
COMBINED SINGLE LIMIT
Ea accident
$
BODILY INJURY (Per person)
$ 25,00
BODILY INJURY (Per accident)
$ 50,00
PROPERTY DAMAGE
(Per accident)
g 2S,OO
COMP/COLL
$ 500/50
UMBRELLA LIAB
EXCESS LIAB
OCCUR
CLAIMS -MADE
EACH OCCURRENCE
S
AGGREGATE
$
DED RETENTION 5
$
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y / N
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
(Mandatory In NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
N / A
PER OTH-
STATUTE I I ER
E.L. EACH ACCIDENT
$
E.L. DISEASE - EA EMPLOYE
$
E.L. DISEASE - POLICY LIMIT
$
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
2006 CHRYSLER 300C SED 4 2C3LA63H26H509160
2001 CHEVROLE SILVERAD PKP 4 2GCEC19T911396791
L911A 10 Ltl a 4 W-1I
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
Supple -Merrill & Driscoll Inc.
U0 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD