2022/08/21 American Forensic Nurses, Inc. (6),acopiJ CERTIFICATE OF LIABILITY INSURANCE OATE (X /DO/YYYY)
at1712022
THIS CERTIFICATE IS ISSUEO AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMENO, 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: tf the certlficate holder is an AOOITIONAL INSUREO, the policy(ics) must have ADDITIONAL INSURED provisions or bo ondors€d.lf SUBROGATION lS WAIVED, Bubject to the t€rms and condations of th€ policy, certain policies may requlre an endorsomont. A stalemont on
lhis certificate doe6 not confer right6 to the corliflcato holder in lieu of such endorsement(s).
PROOUCER
Jackson & Jackson lnsurance
302 E Foothill Blvd
San Dimas CA 91773
Lori Patlerson
PhONE 626-914-9944 626-914-1M0
tnsutance com
AFFOROING COVERAGE
rNsuREF A : James River lnsurance com a 12203
It{3URED
American Forensic Nurses lnc.,
P.O. Box 1625
La Quinta CA 92253
lNsuRER a: State on lns. Fund 35076
INSUEER C
INSI]RER D
INSURER E
INSUFER F
COVERAGES CERTIFICATE I,IUMBER: 1 344014131 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUEO TO THE INSURED NAMEO ABOVE FOR THE POLICY PERIOO
INDICATED, NOTWITHSTANOING ANY REOUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDEO 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.
INSRLTR TYPE OF INSURANCE SUBR POLICY EFF POLICY EXP lttltTs
X COMMERCIAL GETIERAL LIABILITY
CLAIMS.MADE OCCUR
GEN'I AGGREGAIE LiMITAPPLIES PER
x JECT LOC
X
00063557 8 8t2112022 4t21t2023 EACH OCCURRENCE $ 1.000.000
OAMAGE TO RENIED
PREMISES lEr a.r,tr.n..1 $ 100.000
MEO EXP (A.v do oeBd)$ 5,000
PERSONAL & ADV INJURY r 1.000.000
GENERAL AGGREGATE $ 3,000,000
PROOUCTS. COMP/OP AGG $ 3.000.000
$
AUTOiIOBILELIABILITY
OWNED
AUTOS ONLY
HIREO
AUTOS ONLY
SCHEDI]LED
AU'TOS
NON.OWNED
AUTOS ONLYX
00063557 8 8t2112022 4t21t2023 COMBINEO SINGLE LIMIT $ 1.000,000
BODILY INJURY (Por person)$
BOOILY INJURY (P6r a@kj6nl)$
$PROPERry OAMAGE
$
UfBRELLALIAB
EXCESS LIAB
OCCUR
ctarMs-MAoE
EACH OCCURRENCE $
$
$
AGGREGATE
0E0 RETENTION I
I WORXERS COIPEIISATIOT
AND E*PLOYERS' UAAILTY
ANYPROPRIETOF'PARTNEF'EIECIJTIVE
OFFICEI{/UEMB€R EXCIUOED?
oESCRIPTION oF OPERATIoNS b€roh
9225103.2022 '131t2023 X PERSTATUTE OTH
E L EACH ACCIDENT s 1,000,000
E L OISEASE. EA EMPLOYEE $ 1,000,000
E L OISEASE, POLICY LiMIT $ 1,000,000
00063557,8 8121t2422 at21DA23 1,000,000
3.000,000
OESCR|mON OF OPERAITONS / LOCAllOllS /VElllCLEa (ACORD l0l, Addhlon.l R.m. lt Scn dul.,r.yt ttt ch.rt tlttrd.pe l. Eqshd)
All endoGements are applic€ble per writen contract.
RE: Menifee Police Deparlment; Forensic Services. The City of Menifee and its offic€rs, ofiicials, employees, agents and authorEed volunteers are included as
additional insureds, with regard to general liabilily. professional liability and 8uto liability of the named insured, per attached form AP2009US 04-,l0. Waiver of
subrogation included per torm AP50O4US I 1-06 Primary and non-coobibutory wording included per attached brm AP$31US M-10. Workers compensaton
waiver of subrogalion per atlached form 10217 4-2UA. Professional Liability and General Liability deductible per claim is $2,500 each. 30 days notice ot
cancellation, excepi 10 days notice for non-payment ol premrum.
CERTIFICATE HOLDER CANCELLATION
City of Menifee
29844 Haun Road
Menifee CA 92586
USA
SHOULD ANY OF THE ABOVE OESCRIBED POLICIES BE CANCELLEO SEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE OELIVERED IN
ACCORDANCE wlTH THE POLICY PROVISIONS.
AIJTHORIzEO REPRESEUIATIVE
F1orfu
@ 1988-2015 ACORD CORPORATION. All rights ressrv6d
Tho ACORD namG and logo are regislersd marks of ACORDACORD 2s (20r6/03)
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113112022
American Eorensic Nurses, Inc.
Policy #00063557-8
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A[ Colr'ER^OE PAiTS
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3. Tlt lllwrr do.. nd .991y lo bdy hlry or lloprty dl'lrg.' .rlLE oI ot .yolr
rvct'or )ou producf [Ef.d.d h lha !,tcdtEf - co.t$.r..t op.'rlq! hrrtf unh.
)q| rr rxlrld b Fovlda r,lch corsE by lttan conltd 6 urlllln .eit rrt M only
b. 0r pdlod of llna rtqrfrtd by tI rllnrn cootact d wdlfi .grr.lrtad rnd o.ly for
todfy kit'},. o, ?op.rry &tI'!.' ttd o(oJr ttuthg $r polcy F.lod r tre out d }!urr,!rf d .yot p.odt d.
a. Any @rrargr pro{dad by t t andqt.rral b r A.Utond & .d dll D. @aa ovlrfr, olrr( YrE .nd oolctH hr r ttdd. io tha Aardlond h]ttd irror..
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tl.elgano ol lha Aldlbld lr!.rrtd.
Tltl! E @RtEI!.r{T CXAXOET THI FOUCY. PLl lE RIAD
'T
CARIIULLY.
ADDITIONAL INSURED AS REQUIRED BY
WRITTEN GONTRACT
ALL OYHER TERE AIIO COIONON! O' T}G FOi.EY RIXAIX UNC}IAM'!O.
AP:XFEUS O'.10 PT!'l ol 1
Iha Co,rp3ly rgtat to x6h. fly dght of rEylry lgfhrt any p.co.r or qg.nltlbo, .!nslhd by rdtan conf.cl, b.crjta of prym.dr w. nr.h. tr lnll,y fi (brn{r $idt I tnt.d
b l.bfry dHy c.'Ir.d by'yotI rlqt' wtfdt b llnpoild b rrdr prE r or orirn&Abn.
American Eorensic Nurses, Inc,
Policy *00063557-8
rHta EI{OOi'EXI!{T C}lA'{OEt THE POUCY. PI-EAIE REAO IT CARFEULLY.
WAIVER OF SUBROGATION AS REQUIRED BY
CONTRACT
Tlta .rdCra,trol modIbr htu.atEa ptgvtfu tln&r ola ft0oilng:
ALL CI!r'ERAGE PARTS
ALL OTTIER TERMS A'lD @ Omol{t OF TH! FOUCY REXAIN I,iICHAI'OED.
APEoo'ru8 tl40 P0AII o{ t
Amer.ican Forensic Nurses, Inc,
PoIicy #00063557-8
rirt-CNDoitflErar cllAr{o!! Tr{E ?oucy. PLEAIG RlAo Ir c^fiE?uLry.
PRIMARY AND NON CONTRIBUTORY
ENDORSETTIENT
Tllb rrxblJmm rnodmcr haumcc provldod srxlr lrr lobrlne:
AI COVERAOG PARTS
ALL OTttER TERT'S AI{D @tlqTlo ! OF THE POUCY REXAIN UI{CI{A}IOED.
Anry @i,.rtec p.uldod b an Aaldtonal h.uttd u.r(,i lhb polcy thdl b. .Eo ot,t any oolt
vdld lld @6a lnrrtlrca 6rdE! b rrch Addbnrl Lr[d irn frrf prhrrr, q(,3r,
oo,rlhganl c on .,ry oth.r b..b wlr a wrltbn or{,.d q urlbn .e rrtn nr tPrchcdt
rtqul,tt lhrt ttrh hrranco rppty on r grtn ry and rEnonllbt !.y brd3.
Per vrritten contract
m 5.o9c.t
-r{tr,'L!t:
AP66lt S O+r0 P.0. 1 of t
HOME OFFICE
SAN FRANCISCO
ENDORSEMENT AGREEMENT
WAIVER OE SI'BROGATION
BI"ANKET BJASIS
EPFECTM alanu.ry 3L, 2022 AT 12:01 Al{.
AI{D EXPIRING January 3L, 2023 AT 12:01 AU
9225tO3-22
RENEWAT
Page 1
Los Anteles
9881794
ALL EFFECNVE DATES
AT 12:01 AM PACIFIC
STANDARD TITIE OR THE
TItiE INDICATED AT
PACIFIC STANDARD NME
AMERICAI{ FONENSIC NURSES, INC
PO BOX 1625
LA QUtNTA CA 92247-1625
WE HAVE THE R]GHT TO RECOVER OUR PAYMENTS FROM ANYONE L]ABLE EOR AN
INJURY COVERED BY THIS POLICY. ['IE ViILL NOT ENFORCE OUR RIGHT AGAINST
THE PERSON OR ORGANIZATION NAME D IN THE SCHEDULE.
THIS AGREEMENT APPIIES ONLY TO THE EXTENT THAT
A WRITTEN CONTRACT THAT REOUIRES YOU TO OBTAIN
//f.u/
AUTHOREED REPRESEMTATIVE2572
sclFFoR tq2tT (REv. a -2or8)
YOU PEREORM WORK UNDER
THIS AGREEMENT FROM US.
THE ADDITIONAL PREMIUM FOR THIS ENDORSEMENT SHALL BE 2.OO* OF THE
TOTAL POLICY PREM]UM.
JOB DESCRI PTION
ANY PERSON OR ORGANI ZATION
FOR WHOM THE NAMED INSURED
HAS AGREED BY WRITTEN
CONTRACT TO EURNISH THIS
WAIVER
BLANKET WAIVER OF SUBROGATION
COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: January 19, 2022
NOTHING IN THIS ENDORSEMENT SHALL BE HELD TO VARY. ALTER, WAIVE OR EXTEND ANY OF THE IERIIIS, CONDIIIONS,
AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER IHAN AS ABOVE STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL
BE HELO TO VARY, ALTER, WAIVE OR LIMIT THE TERMS. CONDITIONS, AGREEMENTS OR LIMITATIONS IN THIS ENDORSEMENT
PRESIDENT AND CEO
olo oP?17
STATE
coMParat^YroxrxSur^i.caFUNtr,
SCHEfULE
PERSON OR ORGANI ZAT I ON
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