2022/05/15 American Fidelity Assurance CompanyA,CORD CAMEASSOl C
CERTIFICATE OF LIABILITY INSURANCE 8t31t2022
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 CONTR,ACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: lf the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed.lf SUBROGATION lS 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).
INSUREO
American S irit lnsurance CompanyN
I [iI,,",,(aos) sss-zesz
renKa H ma ocm
c Great
NSURlCA.com
Karen S. Hammock, ClC, CRM
fJ3,Nri., e,q, (ao5) 5s6-2328
tNsuRER B : Great American lnsurance com
20303
33723
16691
INSURICA - Oklahoma City
5100 N. Classen Blvd. #300Oklahoma City, OK 73'118
American Fidelity Assurance Company
cio INSURICA, lnc.
P.O. Box 25928
Oklahoma City, OK 73125
INSURER O
INSURER E
EVISION NUMBER
INSR TYPE OF INSIIRANCF
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAI\.,I ED ABOVE FOR THE POLICY PERIODINDICATED. NOTWTHSTANDING ANY REOUIREMENT TERM OR CONOITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR [,4AY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRiBED H EREIN IS SUBJECT TO ALL TH E TERMS
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LII\,{ITS SHO!\N I\,IAY HAVE BEEN REDUCED BY PAID CLA]I\4S,
SU POLICY NUMBER LIMITS
EACH OCCURRENCE
DAMAGE TO RENTEDPRFIMISFS lF. o..uren.el
UED ExP (any one person)
PERSONAL&ADV NJURY
3
1,000,000
1,000,000
1,000,000
10,000
GENERAL AGGREGATE
A COMMERCIAL GENERAL LIABILITY
X
x
x
OCCURctAll\4s I,ADE
L AGGR
POLICY LOC
EGATE LIMITAPPLIEI -l pno- I -l
I tJECr I
35388680 9t't t2022 9r1t2023
PRODUCTS COIVP/OP AGG
$
s
5,000,000
lncluded
COIMBINEO SINGLE LIM]T 1,000,000s
BODILY NJURY
B
OWNEDAUTOS ONLY
H REDAUTOS ONLY NON.OWNED
x
AUTOMOBILE LIABILITY
SCHEDULEDAUTOS
cAP339214611 5115t2022
EACH OCCURRENCE
AGGREGATEEXCESS IIAB
I]f D RETENTION S
OCCUR
CLAIIlS MADE $
$x
E L EACH ACCIDENT 1,000,000$
WORKERS COMPENSATION
ANO EMPLOYERS' LIABILITY
ANY PROPRIETORFARTNER/EXECUTIVEOFFICER/MEMBER EXCLUDEO?
DESCRIPTION OF OPERAIIONS below
l-"
339217203
N
511512022 5t't5t2023
EL DISEASE EA EMPLOYEE
E I OTSFASF POt tCY I i,4tl
$
$
1,000,000
1,000,000
DESCRIPTION OF OPERAIIONS / LOCAIIONS / vEHICLES (ACORO 101, AddilionalRemarks Schedule, maybe attached if more space is required)The City of Menifee, its councilmembers, officers, agents and employees are Additional lnsureds on a primary and non-contributory basis as respects General
Liability if required or agreed to in a written contract subject to all provisions and limitations of the policy. The general liability includes a separation of
insureds clause. 30 Day Notice of Cancellation applies in lavor of the certificate holder.
CATE LDER CANCELLATION
@ 1988-2015 ACORD CORPORATION. All rights reserved
The ACORD name and logo are registered marks of ACORD
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORETHE EXPIRATION OATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS-
f7/J- .A-^L
AUTHORIZED REPRESENTATIVE
City of Menifee
Department of Finance
29844 Haun Road
Menifee, CA 92586
ACORD 25 (2016/03)
TNSURER a : Great Northern lnsurance co.
u
5n 5/2023 Lggqlly llllBy lEer p!u.nl]-s
$
L
OTN
ACORiJ
COVERAGES
CERTIFICATE OF LIABILITY INSURANCE
CERTIFICATE NUMBER: 1 123693921 REVISION NUMBER
DAIE I[f,/DO/YYYY)
1t2't2022
THIS CERTIFICATE IS ISSUEO AS A MATTER OF INFORMATION ONLY ANO CONFERS NO RIGHTS UPON THE CERTIFICATE HOLOER. 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 T}IE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: lf the cerllUcate holder is an ADDITIONAL INSUREO, the pollcy(les) must have AODITIONAL INSURED provlslons or be endorsed.
lf SUBROGATION lS WAIVEO, subject to the terms and condilions ot the pollcy, certaln pollcles may require an endorsemenl. A statement on
this certlticate does not confer.ights to the certificate holder in lie! of such endorsement(s).
PRODUCER
Jackson & Jackson lnsurance
302 E Foothill Blvd
San Dimas CA 91773
INSURED
American Forensic Nurses lnc.,
P O Box 1625
La Quinta CA 92253
License# FBO058E884
AMERFOR.Ol
LOIt Pallerson
filll,Eo. .,u.q23.9 r +-gsaa
fffiles, loli@jjlnsurance.com
[iI, ror, 626'e14'1040
I SURER S
ItISURER C
lr,ISURER D
INSURER E
lt{ suRE Ris) aFFoRotNG covEttAGE
James River lnsurance Company
Slate Compensation lns. Fund
12203
35076
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED AAOVE FOR THE POLICY PERIOD
INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY 6E ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIAED HEREIN IS SUBJECT 10 ALL THE TERMS
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
'I#. rypE or ,{3uRAr{cE lii1*m polrcy NUxaER ,i8,{8l,{ii' [riTigf,ffi] L rs
X CO I.ERCIAL GENEiAL UAALTY
| l
"*,uouoo. ixlo""r"
Y Y 00003557-7 812112021 8/2112022 E{cHoccuRRENcE
I taf,rmE ratIE&TED
L pREMlsEs (Es o@m@)
s 1000.000
s 100 000
s5000
s 1.000,000
s 3.000 000
s 3.000 000
5
il
"o.,"., l l !E& l- I .o"
OTHER:
MEO EXP (A.y d6 p€@n)
I pensouL a lov ntLunv
AUTOMOBILE LIABILITY i 0006t557-7 al2112021 a/21/2022 COMBINEO SINGLE LIMIT(Ea a@ld€nll
BODILY INJURY (P p6rsor)
BODILY INJURY (Por accide.l)
PRoPERTYDAMAGE
Iellcsqldql)
t 1,000,000
$
EXCESS LIAB
I o..u^
I ".o,ua-,r-.oEo REIENIiON$
EACHOCCIJRRENCE
AGGREGATE
5
s
s
WORKERS COIIPENSATloN
ANO EYPLOYERS' LIABII.ITY
ANYPROPRIETOR/PARTNEAYEXECUTIVEOFFICER/MEMAEREXCLUDEO?
DEscRtPTtoN oF oPERATtoNS b€te
I 9225103-2A22 1t3'112022 1i31i2023 x lSiIrurE I EoIt!
EL EACH ACCIOENT[i;.. .;;;;J
[.-"*"a_ *a,.a 'arrrl
51 000.000
s 1.000.000
s 1.000.000
A P.olsr.lcnalLEni'ry 00063557-7 at2't2c21 8t2112422 1 000 000
3 000 000
DESCRIPTION OF OPERAnOIS / LOCATIOIiS / vEBlclES IACORO I 01 , Additlo.rl R.mrrk. Sch.dul., m.y b. llllch.d ll mor. rp.c. i! r.qun.d)
Ailendorsemenls are applicable per wrillen contrac,t.
RE: Menifee Police Deparlmenl Forensic SeNices. The City of Menifee and ils officers. ofllcials, employees, agents and authorized volunleers are included as
addilional insureds. wilh regard to general liability, professional liability and aulo liabilily of the named insured, per attached form AP2009US 04-10. Waiver of
subrogation included per form AP5004US 11-06. Primary and non-conlribulory wording included per attached form AP5031US 04-10. Workers' compensalion
waiver of subrogalron per attached form 10217 4-2018. Professional Liability and General Liability Deduclible per claim is $2,500 each. 30 days nolice of
cancellaton. excepl 10 days notice (or non-payment ol premrum.
CERTIFICATE HOLDER CANCELLATION
City of Menifee
29844 Haun Road
Menifee CA 92586
USA
STIOULD ANY OF THE ABOVE OESCRISEO POLICIES SE CANCELLED BEFORE
TTIE EXPIRATION OATE THEREOF, NOTICE WILL S€ OELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS,
AUTHO RIZE D RE PR ES ENTATIVE
dor,CIe
ACORD 25 (2016/03)
T
1
ANY AI]TO
OWNFD SCHEOULED
AIJTOS ONLY AIJTOSHIRED v NON4WNEOAllros oNLY ^ auros oNLY
L
@ 1988-2015 ACORD CORPORATION. All rlghts reserved.
The ACORD name and logo are roglstered marks ofAcoRD
American Forensic Nurses, Inc.
PoIicy #00063557-7
ADDMONAL INSURED AS REQUIRED BY
WRITTEN CONTRACT
Ihb .n(brtorlrnt modfia. hrr]p pro,tthd on(,.r lh. Hbwlng:
AII CC^/ERAOE PARTS
SEC foll ll-Wto bAn llrlr,.d b mnd.d b lndr('c ]ty Floo ot or!trti.rtdl you rrt
rut hd b lndrb a3 an ddHond r rtd m tib Dolcy by x,tltLn cmurct d rilEt {ll.lmnt-nhra Utre m pofcy pbd rd .I'errd pf* b lh.'@rldr'ottht'to.fly hF)" o,
TrcPqryd.tle..'
Iha lnf,nncr ptovld€d b tll. A(Etbnal lnrrad wd.. tl. andoilr rth lHtrdlrl q'rr:
r Th.6lrdr aorE lrEltbrIod,ndEolld lE ]ad $lh rxpacl b Lllly rurle" ri,[ rrt Cf.; wsl( o. ]qr'Eodt d YfiUl b lflDllbd b 0r Aardlqt lk:lltd.
2- h tr..Y. Gaa lt[ UmIr ol lnrrrn prorfdrd by lhlr polcy.[Ga.d tr. Ultta d- i;.-.E tuftad bv ttr rrtn orrna o. rlltio aeF! rrd.lra hrUra FlUibd ',rr-r-noqr:*l *rir D. tr|l- b o. Llttrt oa l rrn lrqtt]td by-t't fitn drd
;;iiE ifi;til. ta cnomngl rll mt Errr li' ur'b ol h'linct 'lrbd kr
lh.ffirlrlr
3. Itb tnrr!!. dd trol Qly b to(Iy hir},. or lloFly dttEg" rfhe ad-of !t,* ;tsd' hr, DtEdtd'-indiriea rr rrr haiotilr - qrrp'rrd qrltrdr hqf tlt'er
iE;finid b rrtd. rdr oYr.il b, gt!.lt contrEtar tbn qwr'nl Mor{y
frio. pilid oltha rrqdrd by h rtlt ncontncl'w rl qrxflllt'rr o'ry tor
fi;iilof;"nF,ivocmigc' traoornduihe ut' pd'ry Fbd rhlrr ot'l d1rq'r
wqf oa .}tr, plt,dt d.
a. Anv @!ralt!t Provldad !y 0{t rdqmant b fi A'ldtold lnotnd drrl D' cc't' ot'!(* fi ffi';fr-ini iaur,iUc tnsro rvldo b th. ffitqd hutd nhcut'r
ffily, rxcrs, contnprt or on rry o0tc? bd'
a trylm no @YLtg. l,dcr lHa pol'Ey tfrl ryty lbt !r
'{tT
r'd lntultd' oo covtrrgt q
d.i.tr .hd ba dbIdd b lh. Arldl&(ll r!rr'0'
0. Il{. h{rllo! do.. rEa Tglv b lo(Iy l4t'll d ?rcFry om'et' rlrhe o|n ol lh' Fl'
nadeanra ol ffr AEltldrl llEuttd'
THI! ENOORIEIEXT C}IAXOES THE FOUCY. PLEASE RIAD lt OTRER'IIY.
ALr orHER?ERXt AXO COlUnol.! o? Tl{! PouqY RlxAlN ul{ctl llGED'
Agrxneu8 0r-t0 Prgc t ol t
American Forensic Nurses, Inc.
Policy #00063557-7
nr CooFny tnat to srhr. my deht ol rrcowry roBlnd any 9..!d or oerntsffn, ar
,tan lrrd b, Irltbn contr!.i, bc€rrx d pq^r'r.nb st nrha tr lrtry r tbnrqr rlidt b &nltrd
b lrDl!ry ffiy c.l'!!d by .yEuf urort'x,tradr b |tnBicd b n d| pdlon or olitr,lEdlon.
r AE DOAIE EIIT C}IANOES I}IE POUCY. PI-EATE REAO IT CARFEULIY.
WAIVER OF SUBROGATION AS REQUIRED BY
CONTRACT
TH! cllddtalrrlt modlb! haurrro provld.d un tr tla Hl lng:
ALL GOVERAGE PARTS
A[ OTHER ?ER 8 AIID @NDITIONE OF
'TIE
FOUCY iEf,AIN UI{CI{AIICED.
AP5004US t',r{,o Pagetdl
American Forensic Nurses, Inc.
Policy #00053557-7
Tfti!.ElDOd'gE,fT CHA}I(f,! rHE FOLICY, PLEAIE READ ]T CARETULLY.
PRIMARY AND NON CONTRIBUTORY
ENDORSEMENT
na ro(Etartrm modfb. frrrrro pDvtdcd unftr th. fobrrh$
^LL
@VERAOE PARTA
Any @v]rlc Flvld.d b an Arldtond lrurtd urdd lrb potoy tfal b. .rc[. orrr rnv oof,ry d rd Ef.crua mnrna !\rrlhu! b ruah Addltnat lnerid vrffirrr prtrrt , oqlr.€r/ll|lt$ T.g:r llty otFr b.rb url5. wrltbn ontrd or nrrlbn agrucrnint rfi{Uy-'rtqullta thal th'r hrnrp apoly on a Ddrf,ry and mnconfibuto.y bada.
ALL qTHER TERXT A D COITUNO ! OF ITIE FruCV REf,AIN UNCHATOED.
Per rrritten contract
IE tPP Il b
AP6G!Us O+10 Pre. 1 ot ,l
lri I i-:.!
ENDORSEMENT AGREEMENT
WAIVER OF SUBROGATION
BLANKET BASIS
9215tO3-22
RENEWAT
PaSe 1
Los AnSeles
9881794
ALL EFFECTIVE OATES
AT 12:01 AM PACIFIC
STANOARO TIftTE OR THE
TIME INOICATED AT
PACIFIC STANOARD TIME
AMERICAN FORENSIC NURSES, INC
PO BOX 1625
LA QUINTA, CA 92247-1625
WE HAVE THE RIGHT TO RECOVER OUR PAYMENTS FROM ANYONE LIABLE FOR AN
INJURY COVERED BY THIS POLICY. WE WILL NOT ENFORCE OI]R RIGHT AGAINST
THE PERSON OR ORGANIZATION NAIIED IN THE SCHEDULE.
THIS AGREEMENT APPLIES ONLY TO THE EXTENT THAT YOU PERFORM WORK UNDER
A WRITTEN CONTRACT TT{AT REQUIRES YOU TO OBTAIN THIS AGREEMENT FROM US.
THE ADDITIONAL PREMIW FOR THIS
TOTAL POLICY PREMII]M.
ENDORSEMENT S}{ALL BE 2 OF THE
JOB DESCRI PT]ON
BLANKET WAIVER OF SUBROGATION
00?
ANY PERSON OR ORGANI ZATION
FOR WHOM THE NAMED INSURED
IIAS AGREED BY WRITTEN
CONTRACT TO FURNI SH THIS
WAIVER
NOTHING lN THIS ENDORSEI\,4ENT SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERi,.4S, CONDITIONS,
AGREEMENTS. OR LIMITATIONS OF THIS POLICY OTHER THAN AS ABOVE STATED, NOTHING ELSEWHERE IN THIS POLICY SHALL
BE HELD TO VARY. ALTER. WAIVE OR Ll[rllT THE TERt\rS. CONDITIONS. AGREEMENTS OR LIMITATIONS lN THIS ENDORSEMENT
COUNTERSIGNEO AND ISSUED AT SAN FRANCISCO: January 19,2022
at4
AUTHORIZED REPRESENTATIVE
2572
sctF FoRM 10217 (REV.4 -2013)
PRESIDENT AND CEO
STATEcoMraraarroNrxlr,, IArac aFUND
HOME OFFICE
SAN FRANCISCO
EFFECTM January 3L, 2022 AT 12:01 AM.
AND EXPIRING .ranuary 3L, 2023 AT 12:01 AM
SCHEDULE
PERSON OR ORGANI ZATI ON