2022/08/21 American Forensic Nurses, Inc. (5)ACoRi}CERTIFICATE OF LIABILITY INSURANCE
Lise,!ee#r FeO050E984
AMERFOR"Ol
CERTiFICATE NUMBER: 220067183
PROOUCER
Jackson & Jackson lnsurance
302 E Foothill Blvd
San Dimas CA 91773
INSURED
American Forensic Nurses lnc.,
P.O. Box 1625
La Quinla CA 92253
COVERAGES REVISION NUMBER
DAIE (MM/DO/YYYY)
1t2412023
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON TTIE CERTIFICATE HOLOER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMENO, EXTENO OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZEO
REPRESENTATIVE OR PROOUCER, AND THE CERTIFICATE HOLDER,
IMPORTANT: lf the certificate holder is an AODITIONAL INSURED, the policy(ies) must have ADDITIONAL INSUREO provisions or be endorsed.
lf SUBROGATION lS WAIVEO, subject to the terms and condilions of the policy, certain policies may require an endorsement. A statement on
lhis certificale does not confer rights to the certificate holder in lieu of such endorseme nt(s)
lor@jjinsurance.com
INSUEEE(S) AFFORDING COVERAGE
James River lnsurance Comp?!y
Stale Compensation lns. Fund
[il, xa,626 sla-1oao
tNs
12203
35076
ADDRESS
iii3.'n'",."t, 626-9 1 4-ss44
INSIJRER B
INSURER C
INSURER D
INSUFER E
THIS IS TO CERTIFY THAT ]HE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTWITHSTANDING ANY REOUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUI\,4ENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY AE ISSUED OR MAY PERTAIN. THE INSURANCE AFFOROED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS
EXCLUSIONS ANO CONDITIONS OF SUCH POLICIES, LIMIIS SHOWN MAY HAVE AEEN REOUCED BY PAIO CLAIMS,rNsR mDL SIJBF poLtcy EFF poLtcy ExpLTR TYPE OF INSURANCE |NSD UyvD pOLtCyNUMBeR tuiDoiftii) tl|a/Doiyytit U|IIS
EACHOCCURRENCE
-T['A6ETORE N'E D
PREMISES (Ea @cure^ce)
MED EXP (Any one pe6on)
. PERSONA!8 ADV TNJURY
GENERAL AGGREGATE
$ 1.000.000
$ 100.000
$ 5.000
$ 1.000.000
$ 3,000,000
$ 3.000.000
$
Y Y 00063557-8 4t21t2022 4121t2023
OTHER
X COMMERCIALGENEiALUABILITY
l "*,u"-*o. [i o""r^
PRODUCTS. COMP/OP AGG
AUTOSONLY
HIREDAUTOSONLY x
Y 00063557-8A AUTOM OB ILE LIABILITY
SCHEOI]L€OAUTOS
NON,OWNET)
AU IOS ONLY
BODILY INJURY (Per pe6o.)
BODILY INJURY (Per acc denrl
PROPERTY DAMAGE
COMBINEO SINGLE LIIJIT812',12022 at21t2a23
- 1E4?a!lde!!l
EACHOCCURRENCE
I ongq.*r.
DED RETENTION $
OCCUR
CLAlMS MAOEEXCESS LIAB
B woRrGRscofPEt{saTtol
AI{O EIPLOYERS' LIAEIUTY
ANYPROPPJETOR/PARTNEFYEXECUTIVE
OFFICEFYMEMAEREXCTUOEO?o,.nd{o.y ln Nrl)
ll ves descrbe underoEscRtPTtoN oF oPEFetoNs berok
r 1.000,000
r 1.000.000
:
$ 1,000,000
\ 9225103-2023 1t3't2023 1t31n424
EI DISEASE EAEMPIOYEE
E.T DISEASE POLICY LIMIT
It llffi. P-'
E.L. EACHACCIOENT
Y Y 00063557,8 8t2'12022 4t2U2023
DESC RIPITON OF OPERAITONS / LOCAITONS / VEH rC LES (ACORD 101 , Addlronal Rom.rk. Sch.dulo, may bo .nachcd .' mo.e .pace 13 rcqurrod)
All endorsements are applicable per written conlraci.
RE: Menifee Police Departmenl; Forensic Services. The City of Menifee and ils officers, officials, employees, agenls and authorized volunteers are inclLrded as
additional insureds, with regard to general liability, professional liabilily and aulo liability of the named ansured, per atlached form AP2009US 04-10. Waiver of
subrogation ancluded per form AP5004US '1 1-06. Primary and non-conkibutory wording included per attached form AP5031US 04-10. Workers' compensation
waiver of subrogation per atlached form 10217 4-20'18. Professional Liability and General Liability deductible per claim is $2,500 each. 30 days notice of
cancellation, excepl 10 days notice for non-payment of premium.
CERTIFICATE HOLDER CANCELLATION
Caly of Menifee
29844 Haun Road
Menifee CA 92586
USA
SHOULD ANY OF THE ABOVE DESCRIBEO POLICIES BE CANCELLEO BEFORETI.IE EXPIRATION DATE THEREOF, NOTICE WILL BE OELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
dnrafu
ACORD 25 (20't6/03)
GEN'L AGGREGATE LIMIT APPLIES PER
l! ] *.,", !l"o; I Loc
$
$
$ 1.000 000
s
$
$
1,000.000
3.000.000
O 198&2015 ACORD CORPORATION. Allrights rosorvod.
The ACORD name and logo are rogistorod marks of ACORD
American Forensic Nurses, Inc.Policy #000 63557-8
ADDITIONAL INSURED AS REQUIRED BY
WRTTTEN GONTRAGT
f hb .rxblt.rmflt mo.thcr hs,rrE Fo!,ldrd und.r lh. ldlo,ylng:
ArI cc^/ERAGe PARrS
8EC't]Otl ll - Who la An ll.utd b rDrrr.d lo Indrdc .ny parton or orgulz*m yor, .,r
Itqulrtd t lnct,dr rt .n lddnbnal h]r t on thb DoIc, by fftltrn omtrct or rrtlEr ag]rm.nl
h rlLca drhe lhl poacy p.iod rld u.qr.d prbr to lh. 'oan ntno.' ol thc 'bodly hlJr/ or
'pro0.rr, dri.Ca.'
Tho ln'rnnc. pmyldod to thr Addtlonal lnrrrd undr. thl lndo[crmrn b lldlad ra iolowr:
i. Th. Fltdr o.oErnE lbn b mly an addllo.d hirr.d u n r.rp.al b f-afy o.bhg
roaly orrt ol .}un udl( o.lrcrr p.oduaf rr*$ b lrnpur.d b fra Addlqd lrrurtd.
2. ln lha c\onl lha lhc Llmnr ot hf,Jrrn Fovldad by thlr polc, .)(c..d 0r Urnb d
llru'r r ltqlrd by tha xrilan onlrol or rdtbn l0llt m.nl. lha htr'lE 9nc!,lt .d by
lib andql.'trnt alrat ba lrr{d 5 ll. |,.ffi ol l rrtrr tlqdrtd by t]a wrtm ctirGl
a nrtabn tmulxnl ThL rrfi.tatrrit J.ll rDt haraax lhc Llnltt ol h.urno .!tad ln
lr. Harruq|r,
3. Thlr lnrurrr (b.s nd .pply lo iody hiuor or llop-y drtntg.' .tthg qt oI .yol,
wori'or,c, p,odud |tlcl.d.d h !,|a !.odtEb - omd.trd e.nlq! h.z.lf unh.
yn, rt mrH b Fsvlda rrch @waga by u,rtrn conitcl o. wrlntn rgllnrfil bd or{y
id tt pdod of thl. ,tqdEd by ,r lrltLn con$rcl d tYrltEr .grr.nxrt .na, orly ,!r
turrfy Errf or Tropotty damrga' lhrt oorll turhg 0t. poncy p..bd atldng out ot'your
tt orf o. Yol, ploducf,
a. Any @vrlro! proyld.d by Utr .o&(rf,rrrnt to fr A.lChlord ln rtd tlrl bo lrc.tl or.r
art olh..rll5 and coldtb ln:r lo avdlauc to th. Addllqd hotttd l$.thar
Flltl.ry, ax6ttt, conJngont o. m rny o0trr barb.
6. trtlm m cotrtflgc rrxhr lllb pdlsy rtrl ely
'o.
!1a Nrm.d lntuEd, Do covaflgt q
d.irn . rhrl ba arlon !d lo U! At dlllord lnr,r.d.
O. f a hrutanoa doat rlol ?ply b lo(Iy ldlrlr o. 'pme.tty d.rAl.' rthg olll ol lrt El!
oaemca ol tlt Addl0drd kEuttd.
THls E}TOORtEI'E'{T CI{ANOES THE POUCY. PLEASE RIAD II CAREFULLY.
ALL OI}IER TERIB ArlD COI{DINOfl! Of TTG POLEY REXAIN UNCI{AIIOED.
AP2(mus oa-to Prg! t ol 1
Ihc Comprn, .grtat to u6h/€ .rly dght ot rlcov.ry 4alnit tny pdron or ollllnlr.tbn, .t
Itgljkrd b, rrltbfr oontn t bccajlc of pryrn nb w! rmh! tr ln u.y o( dlmloa wlddt b Enttrdb lsDllty dHy c.rud by Your sut' wttkh la lmputcd to srdl pu$n or ootrntsrtlon.
American Eorensic Nurses, Inc.
Policy #00063557-B
THIS E'{OOIIgE ENY C}iAIIOE8 THE POUCY. PtEAS€ REAO 1r CARFEULLY.
WAIVER OF SUBROGATION AS REQUIRED BY
CONTRACT
Tlt Gndd!.flrot mod b! kr|ursno pwldad und€r tho ,olloulrE:
ALL COI'ERAGE PARTS
ALL OTHEN
'ERM8
A D @NOI'IONt OF T}IE FOUCY REIIAIN UI{CHAI{OED.
AP5004US tt46 P.Oo I of t
American E'oren s i c Nurses, Inc.
PoIicy #00063557-8
THiiiExDoilErEI{r cHAxoeS rHE PoLIcY. PLEAIG RIAD ]T CAREFULLY.
PRIMARY AND NON CONTRIBUTORY
ENDORSEMENT
Thl cndo.ramm rEdllc! haurtncc provldad undrr lh. lo fflng:
ALL @VERAGE PARTS
ALL OTHER TERMS AND @ DlnO I OF II.IE POTJCY REXAIN UNCI{ATOED.
Any @ltrago prlvlda{t b an Addfbnd h.urd unfi urb polq, ,El b. .Eaaa ornr any ool.I
ldld rral @LcltL l rt rca lvd$L b rJdr Addlbnd Ln rd yrffi|f prtrrry, uoo.
codnetri oa on .ny othar baab rrlo a wrlttan 6r rad o. x,rlbn lgllm.rt rplcllcdv
raquttr lhrl lhlr hau?an6 rpply ofl a ptt y lrd mnonfibutory brd..
Per written contract
m ba99Cirt
APoOSTUS 0a-r0 Pag. 't ol 1
Or OrErntsad rlrl:ll ln (lr*
}IOME OFFICE
SAN FRANCISCO
EFFECTM .fanuary 3L, 2023 AT 12:01 AM.
AND EXPIRING ,January 3f, 2024 AT 12:01 AM
9225101-21
RENEWAL
Page 1
Los Angeles
9881794
ALL EFFECTIVE DATES
AT 12:0'l AM PACIFIC
STANDARD TIME OR THE
TIME INDICATED AT
PACIFIC STANDARO TIME
AMERICAN FORENSIC NURSES, INC
PO BOX 152s
LA qUtNTA, CA 92247 -1625
WE HAVE THE RIGHT TO RECOVER OUR PAYMENTS FROM ANYONE LIABLE FOR AN
IN.]URY COVERED BY THIS POLICY. WE WI].,L NOT ENFORCE OUR RIGHT AGAINST
THE PERSON OR ORGANIZATION NAMED IN THE SCHEDULE.
THIS AGREEMENT APPLIES ONLY TO THE EXTENT THAT
A WRITTEN CONTRACT THAT REQUIRES YOU TO OBTAIN
YOU PERFORM WORK UNDER
THIS AGREEMENT FROM US
THE ADDITIONAL PREMIW FOR THIS
TOTAL POLICY PREMIUM .
SCHEDULE
PERSON OR ORGANIZATION
ANY PERSON OR ORGANI ZATION
FOR WHOM THE NAMED INSURED
HAS AGF-EED BY WRITTEN
CONTRACT TO FURNISH THIS
WAIVER
COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: January 23, 2023
utltl
AUTHORIZED REPRESENTATIVE
ENDORSEMENT SHALL BE 2 OF THE
JOB DESCRIPTION
002
NOTHING IN THIS ENDORSEMENT SHALL BE HELD TO VARY. ALTER. WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS,
AGREEMENTS. OR LIMITATIONS OF THIS POLICY OTHER THAN AS ABOVE STATED, NOTHING ELSEWHERE IN THIS POLICY SHALL
BE HELO TO VARY, ALTER. WAIVE OR LIMIT THE TERi,4S. CONDITIONS, AGREEMENTS OR LIMITATIONS IN THIS ENDORSEMENT
t* 4t*
2572
soF FoRM 10217 (REV.4 ,2018)
PRESIDENT AND CEO
oLo oP 217
STATE
coMpa NsaTroNINSUFANC!FUNtr,
ENDORSEMENT AGREEMENT
WAIVER OF SUBROGATION
BLANKET BASIS
BLANKET WAIVER OF SUBROGATION