2020/01/31 American Forensic Nurses, Inc. (3) DocuSign Envelope ID:02A44B9B-80B2-4869-BElC-985976DD286E AMER103
.qt vxu CERTIFICATE OF LIABILITY INSURANCE DATE 06/04/2020 )
06/04/2020
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 endorsements.
PRODUCER 626-914-9944 C NTACT Lori A. Patterson
Jackson&Jackson Insurance PHONE 626-914-9944 FAX 626-914-1040
302 E Foothill Blvd (A/c,No,Ext): A/c,No):
San Dimas,CA 91773 E-MAIL .lori@jjinsurance.com
ADDRESS
INSURER(S)AFFORDING COVERAGE NAIC N
INSURER A:James River Insurance Company 12203
INSURED American Forensic Nurses Inc., INSURER B:State Compensation Ins. Fund 35076
P.O. Box 1625
La Quinta,CA 92253 INSURERC:
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 LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY E P LIMITS
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE OCCUR X X 00063557-5 08/21/2019 08/21/2020 DAMAGE TO RENTED 100,000
MED EXP(Any oneperson) $ 5,000
PERSONAL&ADV INJURY $ 1,000,000
GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000
X POLICY PRO LOC PRODUCTS-COMP/OP AGG $ 3,000,000
JECT
OTHER: $
A AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT $ 1,000,000
ANY AUTO X X 00063557-5 08/21/2019 08/21/2020 BODILY INJURY Perperson) $
OWNED SCHEDULED
AUTOS ONLY AUTOS BODILY INJURY Per accident $
AUE� pW PROPERTY AMAGE
TOS ONLY X AUTO ONLY Per accident
$
UMBRELLA LIAB OCCUR EACH OCCURRENCE
DE
CESS LIAB CLAIMS-MADE AGGREGATE $
D RETENTION$ $
B AND EMPLOYERS'L ABILO X ITY X PER OTH-
9225103-2020 01/31/2020 01/31/2021 1,000,000
ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ E.L.EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED? N/A
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000
If yes,describe under 1,000,000
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
A Professional Liab 00063557-5 08/21/2019 08/21/2020 Ea Claim 1,000,000
Retro 11/30/2004 Aggregate 3,000,000
�9cMeniTee Police UepaRment; o�ensicC�er Ces. I IiaeRl.i y or eni1'ea@ 8rip ched If more space Is required)
its officers,officials,employees,agents and authorized volunteers are
included as additional insureds,with regard to general liability,
professional liability and auto liability of the named insured, per attached
form AP2009US O4-10.Waiver of subrogation included per form (over)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of Menifee ACCORDANCE WITH THE POLICY PROVISIONS.
29844 Haun Road
Menifee, CA 92586 AUTHORIZED REPRESENTATIVE
I . 0 �
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