2021/08/21 American Forensic Nurses, Inc. (3)o.Qo'CERTIFICATE OF LIABILITY INSURANCE DAIE (ITM/DOIYYYY)
4t17 t2021
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 AFFORDEO 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: lf the certificate holder ls an ADOITIONAL INSUREO, the policy(ies) must have ADDITIONAL INSURED provlsions or be endorsed.
lf SUBROGATION lS WAIVED, subjecl to the terms and condilions ol the policy, certain policies may require an endorsement. A stalem€nt on
this certificate does hot confer rights to the certiflcate holder ln lieu of such endorsement(s).
PRODUCER
Jackson & Jackson lnsurance
302 E. Foothill Blvd
San Dimas CA 91773
Licensor:F8OO588884
INSUREO
American Forensic Nurses lnc..
P.O. Box 1625
La Ouinta CA 92253
PHONE
r Lori Patterson
e,u, 626-914-9944 [il, nol 62&sl al oeo
ADORESS lo ri@jjin $ ra nce.co m
tNsuRER(S) AFf OROTNG COVERAGE
INSURER B
INSURER C
James River lnsurance Company 1203
State Compensation lns. Fund 35076
INSURER D:
IXSURER E:
COVERAGES CERTIFICATE NUMBER: 871 49348 REVISION NUMBER
THIS IS TO CERTIFY-THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERTOO
INDICATED, NOTWITHSTANDING ANY REOUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR I\,'AY 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,
TYPE OF INSURANCE
$ 1,000,000
$ 1m,000
$lpq
$ 1.000,000
$ 3.000,000
4t21t2021Y 00063557-7
OTHER
4t2112022A L X C OI'MERCIAT GENERAL LIABILITY
cLltrus ueot X occun
PERSONAL & ADV NJURY
GENE RAL AGGR E GATEGEN'LAGGREGATE LIMIT APPLIES PER
X porLcv tE& Loc PROOUCTS - COMP/OP AGG $ 3.OOO,0oO
$
EACH OCCURRENCE
EAIiEGFTdREN-EO
EBEUIqES {Ea oc!u.renc6)
MEO EXP (Any on. pere.)
00063557-7
X
at21t?o21 an112022
SCHEDI]LED
NON.OWNEO
AUTOS ONLY
A AUlOMOBILE LIAB ILITY
OWNED
AUTOS ONLY
HIRED
AUIOS ONLY
RETENTION
EACHOCCURRENCE
AGGREGATE
OCCUR
CLAIMS-MAOE
UMBRELLAL|AA
EXCESS LIAB
OED
WORXERS COI/IPENSATION
AND EIIIPLOYERS' LABILITY
ANYPROPRIETOR/PARTNER/EXECUTIVE
OFFICER/M€M8ER EXCLUOED?
DESCRIPTTON OF OPERAT oNS ber.w
E,L EACH ACC OENT
E L DISEASE, EA EMPLOYEE
E L DISEASE. POLIC / LIMIT
t 1,0m,000
t 1,0m,0(rc
J 1,0m,000
a xY 9225103-2021 1B1nO21 1B1nO22 OTHERSTATUTE
0m63557-7 8t2112021 8121/2022A I Prol€sioB LEb'Iry 1,0m,0m
3,000,000
DESCRIPnON OF OPERATIOiIS / LOCATIONS / VEHICLES IACORD 1Ol. Addnion.l R.m.rt3 Sch.dulo m.y b. .tLch.d it hoo 3p... is 6quaEd)
Allendorsements are applicable per written co ract
RE; Menifee Police Department; Forensic Services The City olMenifee and its offcers, offcials, employees, agenlsand authorized volunteersare included
as additional insureds, with regard lo general liability, professional liability and auto liability ofthe named insured, per attachedform AP2009US 0,110.
V\Aiver of subrogation included per form (over) Certifcate Holder Note: AP50O4US 11{6. Primary and non-cor(ributory wording included perattached form
AP5031US04-10. Workers oompensation waiver ol subrcgalion per attached form 10217+2018. Professional Liabilily and GeneralLiability Deductible per
claimis$2,500each.30daysnoticeofcancellation,exceptr0daysnoticefornon-paymentofpremium.
CERTIFICATE HOLDER CANCELLATION
City of l\ilenifee
29844 Haun Road
Nlenifee CA 92586
USA
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE OELIVERED IN
ACCORDAT{CE WITH THE POLICY PROVISIONS,
AUTHORIZED REPRESENTATIVE
Flot#re=
O 1988-2015 ACORD CORPORATION. All rights reserved
The ACORD name and logo are registered marks of ACORDACORD 2s (2016/03)
l.?^1!ltE?u"
*o" ''"'- I
! r'ooo om
BODILY INJURY (Por por$n) $
BoDILY INJURY(P€r accid€nl)L $
PROPERTYOAMAGE(Per ac.denll
3
$
$
$
American Forensic Nurses, Inc.
Policy #000535s7-7
ADDITIONAL INSUREO AS REOUIRED BY
WRITEN CONTRACT
Itb .fitoltfi rt modnar lrEJrrlE glDyl(,.d ufidlr tha bllowlng:
All COr'ERAGE PARTS
!ECnOI [ -Who L An ll.utld b rrnd.d b lndxt .ny Frofi ot oQrnts on ]ou .,tru rl b lnclxtr aa an ddltlond h]rtd m $b polcy by sl0rn amlaot o, x'llrr {rurar{
in inra- crftg ,tb Flsy P.rbd rd ll.erd pti t hc'mrErpr' olttc'bodly hJt4f o.
!l!9?tydra..'
If. lilrmo. plsvfl.d !o t A(E0q!.1 ln rad utrtj fi rndottrf|ltt lt trt{.d r ft!,,|:
r- Th! Dndr s orE nEatbn b o.dy m aatduond rE/nd s n rapd b l.Uy atdng" rofty cn a for YFff o.ltqn Frditaf rrth b h9u.d b lh. Atldiqd lrulttd'
2- ln tt. .y.at !d lh. Umlta of lnf,Jrfn provffi by url! polcr.lo.d 0t lldr oa- ir*-ru rtcfrd bv ttr urftbn onEaol or wrtrn qrrmrf. $a iu,lra DllvtLd Rill cneilrirmlit b. hr.d bllo ['[rtr olhrrrrrp trqtr]td by-ttr fttn utrcr
tiilrt tgnaflpttt TnN odorrrnm *rll ml h.taaaa lh' Lrnnt ol hrntn trbd h
!r.ffirnqu.
3. Tlft turrE dG noi.PPly b to(try hiry or Vop-ly drrrg" rltl ql-ot )q'-' ,;;i; tlorr orld,Jcf iniuo'ro noro bdorirr - @mC.td or.dqtr ttrzrf unL..
fri;*iiiabF"rtd.Lrtcolr.gr byilt ncofltrEtartltbn {txt bttl orlyffi-rffiAuil ltqltttd by [r r,tlnrn iomra c mut rgnemtr t"d qtry q-
;iliil;;?optitcam{rc' taocorntuthe lht poIc, prbd
'thlng
ort d 1'qrr
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kttt"d irl D' Gott' o,.r" . J.tilyiad.in<lollritrhrrrrrrtff.toth''wlordlil'diltctrr
nrlirly, war, conUpr* c on fly o0trr bd'
3- Wt:t rp drlraagr llldcf lhb Ddlcu t'rl ely k tll Nrmd l]rtl,|ltd' no coYtllgf, a
dsfsD thd Da atudcd lo lhc Ad6,o l lnrtto'
s. ItL harlrloa lb.a rEl ryly b to{y l'l(,)r c Tm9'.ly drm{c dthg out ot ul. Fl!
fuic. ollh.ArElttdld lntr rt.L
THIE ENOORAETET'IT CHAT{OES THE POUCY. PLIAIIE RIAD IT CAREFULLY,
ALL THER TERS AT{D OOIiE|NONS O' THE PTUCY REXAIT{ UNCHA}IOED'
AP200eu9 ot-to P!O! t ol 1
American Forens j.c Nurses, Inc.Policy #00053557-7
Itr @openy agrat to w!tr/. .ny deht of rEttry alEhat any pcrton or orFrErtbn, ar
cqulrrd by li$.n conH, bacallc of p.yrr.dr s! rEk ftr lolury 6 (brn.eo xtddl b &n[!d
b laDf[y dMy c.u$d by ]Elr uto f wucft b kll9{rtcd b 'l$ pclton or oef,nEdlon,
rHl8 ENOORAEIINT CI{AT{OEE THE POUCY. PTEATE REAO 1T CARFEULLY.
WAIVER OF SUBROGATION AS REQUIRED BY
CONTRACT
Tld. ordarllrrr modmcr hauranoe provHrd undor tho Ulowlng:
ALL CO!r'ERAGE PARTS
ALI. OTHER TERMS AIID @NUNONI OF TTIE POUCY REXAIN UNCI{AI{OEO.
AP60O/IUS 'l 'l -06 P.go 1 of t
Amerj-can Forensic Nurses, Inc.Policy #00063557-7
rfiiliExooFserE]irT CHAIIoES THE PoLIcY, PLEAIG RIAD 1T CAREFULLY.
PRIMARY AND NON CONTRIBUTORY
ENDORSEMENT
llra cndqtar lrrodner hur.nca plorM undor th. lubdne:
ALL COVERAGE PARTS
Any Err,rgr prErl&d b .n Addto l hrmd tIrd.. [lb polcil dfl b. .Eo otr? rnv oltrrvjtd frd coLcUtL l rtlro !Yd5L b t rdr Aatdbmf hrr.d wtrc0If prfrly. oari;. -
ry T.9l lny othcr bob ulc.. e. wdttcn or{nct c *rlbn agmminr rPiaUy '
,tqulItr thtf 0ll. krirrnc. .p9ly on a D.hrt,y and rcnonfibutsy bedr.
ALL OilER IERMT A}ID @XD{fi,llt OF IHE POTJCV RilAIT{ UIICITAIIOED.
Per written contract
bIt m lrlry appoorrti!
AP6@IUS 0+10 P39. I of 1
FUND
ENOORSEMENT AGREEMEI{T
WATVER OF SUBROGATIONffi
ll'tERIcAl{ FOBENSIC NIrBttEg, I}tC
PO BOX 1525
rJA QI,INTA, CA 92241
9225LO3-21
AENEI{AI,
sc9-88-1?-9'[PEGE 1 OE 1
IE SAI'E lE B:ISEI l1ro BECO\'8R Oo8' PAiTGXIS rNOU rr[rONELITEIA
'OR
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NOT AIIIORCE OOR RISEI AoIIIIII TEE PIR8ON ORoncrNlzxtloN llltcD Ilf @ 8cEEDt I;t .
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DERDOnX tonf, qIDIR A WRTIIEN CONInTCI IEAI AIOOTRES IOI,!o oBIl'IN tata tGBt&tlI tnou u3.
8EE IDDITIOLII! DRIIGuI! FOR TBIS NDORAET'BII ASAI.L BT
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JOB DEACR,IPTION
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M'IHII{G ItI' THIS EI{DOASEIiENII SHALL IE HCLO TO VARY, ALYEA, WAIVE ON EXTCiD
AlfY oF rllE rEnt.a, cor{uflor{8, aonEEfEt{rs, ofi umtTATtoNS oF rHtS poltcy
onIe ?HArr a3 arovE rtaTEo. xolHr G EL3EW|*RE m tHtS FolJcy SHAll !E
HELL TO VAAY, AL?Efi, WAIVE OB Ur]t Tt{E tEF t3, COiI']ltOt{S, AOtEEitE tt3 OB
LIUITA?IOIIS I?{ ?HII ENDfiSEME T.
COI,IITCnSIONEO AI{D ISSUED AI 8AN FBANCISCO 2021/-,-, J/-;.**
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STATE
tffiH^?BS. EFEEcrrvE .r NIIARY 3L, 2o2t Ar 12.01 A.M., .erirD EXPIRTNG arANurRr 37, 2022 AT 12.01 A.H.ALL Ef;CrCTlvE O lllt AnEar izot
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PACIEC 8T$DAND fl E
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PIB]SON OR OROlllI ZAUON