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2021/08/21 American Forensic Nurses, Inc.SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME:CONTACT (A/C, No):FAX E-MAILADDRESS: PRODUCER (A/C, No, Ext):PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES 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). 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. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD 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. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED? (Mandatory in NH) DESCRIPTION OF OPERATIONS below If yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT EROTH-STATUTEPER LIMITS(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)POLICY EFFPOLICY NUMBERTYPE OF INSURANCELTRINSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCE DAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO-JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIRED AUTOS ONLY 10/21/2021 Jackson &Jackson Insurance 302 E.Foothill Blvd San Dimas CA 91773 Lori Patterson 626-914-9944 626-914-1040 lori@jjinsurance.com License#:FBO0588884 James River Insurance Company 12203 AMERFOR-01 State Compensation Ins.Fund 35076AmericanForensicNursesInc., P.O.Box 1625 La Quinta CA 92253 187810348 A X 1,000,000 X 100,000 5,000 1,000,000 3,000,000 X Y Y 00063557-7 8/21/2021 8/21/2022 3,000,000 A 1,000,000 X Y Y 00063557-7 8/21/2021 8/21/2022 B XY9225103-2021 1/31/2021 1/31/2022 1,000,000 1,000,000 1,000,000 A Professional Liability Retro 11/30/2004 00063557-7 8/21/2021 8/21/2022 Each Claim Aggregate 1,000,000 3,000,000 All endorsements are applicable per written contract. RE:Menifee Police Department;Forensic Services.The City of Menifee and 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 04-10.Waiver of subrogation included per form AP5004US 11-06.Primary and non-contributory wording included per attached form AP5031US 04-10.Workers'compensation waiver of subrogation per attached form 10217 4-2018.Professional Liability and General Liability Deductible per claim is $2,500 each.30 days notice of cancellation,except 10 days notice for non-payment of premium. City of Menifee 29844 Haun Road Menifee CA 92586 USA DocuSign Envelope ID: 3438D015-5B7E-42EB-A832-8B7A78BCB3E8 American Forensic Nurses, Inc. Policy #00063557-7 DocuSign Envelope ID: 3438D015-5B7E-42EB-A832-8B7A78BCB3E8 American Forensic Nurses, Inc. Policy #00063557-7 DocuSign Envelope ID: 3438D015-5B7E-42EB-A832-8B7A78BCB3E8 American Forensic Nurses, Inc. Policy #00063557-7 DocuSign Envelope ID: 3438D015-5B7E-42EB-A832-8B7A78BCB3E8 DocuSign Envelope ID: 3438D015-5B7E-42EB-A832-8B7A78BCB3E8