POLICY _EFFECTIVE mammy) ANY AUTO OTHER TI IAN EA ADD 6. AUTO ONLY AGG a WES& / UMBRELLA LIABILITY EACH OCCURRENCE $ _

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1 ACORD CORPORATION. All rights roservo ACORD name and logo are romstorod marks of ACORD priabucer E. LOGANS INSURANCE SERVICES 642 3rd Avenuo Suite 13 Chula Vista CA INSURED Fourth DiStrict Seniors Resource Center th. Street San Dlogo CA CERTIFILATE OF LIABILITY INSURANCE _ DATE (MNI/DD/TYi'Y) 01115/2013 THIS 'CERTIFICATE IS ISSUED AS A MATTER OF NFORMATION ONLY AND CONFERS NO RIGHTS :UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND', EXTEND OR ALTER THE COVERAGE AFFORDED B( : THE POLICIES BELOW. INSURERS AFFORDING COVERAGE INSURER & NONPROFITS INS. ALLIANCE OF CALIF. INSURER IV INSURER C: INSURER I); INsuRER E.: COVERAGES THE POLICIESOFINSURANCE LISTEDBELOW HAVE BEEN ISSUEDTOTFIE INSUREDNAMEDABOVE FOR THE POLICY P.ERIODINDICATED.NOTWITHSTANDINO ANY RDOUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OT 1ER DOCUMENT WITH RESPECT TO whic s.certjficate.: MAY BE OR MAY pertain,thieinsuranceaffordedby THE POLICIES DI.7SCRIBEDHEREIN IS &Mil ECTTO ALL THE"I"ERMS, EXCLUSIONS AND CONDITIONS OF,SUCH POLICIES, AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 'NM ADDV :LT NSR typf tininsurande POLICY NUMBER.. POLICY _EFFECTIVE mammy) :POLICY EXPIRATIM1 DATE VAMIOpprtro R. LIMITS. NAIC It,GENERAL LIABILITY EACH OCCURRENCE $ X X COMMERCIAL GENERAL LIABILITY NPO -DO 19119/ /19/2813 jazzg,712, o i CLAIMS MADE X1 OCCUR.MED EXP (Antoho peirsok $ PERSONAL & ADV INJURY $ LOC GENERAL AGGREGATE $: _GM AGGREGATE:LIMIT APPLIES PER: rrobucts - comp/op A00. $ X P01 ICY r AUTOMOBILE LIABILITY x L. X.: ANY AUTO / I19/2013,.(Hn ActIdenI) X : ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS COMSINEO.SINGLE LIMIT 1,000,0,00 BODILY' MUST (Porpoiton) BODILY INJURY X NON-OWNED AUTO (Per Stalefit) PROPERTY DAMAGE,(Per scoident) GARAGE LIABILITY AUTO ONLY,EA ACCIDENT $ ANY AUTO OTHER TI IAN EA ADD 6. AUTO ONLY AGG a WES& / UMBRELLA LIABILITY EACH OCCURRENCE $ _ OCCUR I j CLAIMS MADE. AGGREGATE : -- I DEDUCTIBLE $ RETENTION $. $ WORKERS COMPENSATION I WC STATU I 0TH. AND EMPLOYERS' LIABILITY _TORY LIMITS.' Y I.N ER, ANY,ROPRIETORIPARTNERIEXEOUTIVEr-1 EL. EACH ACCIDENT $ OFPIC,ER/MEMBEREXOUIDED? 1 I (Man Mtbry In NH) EL DISEASE- EA EMPLOYEE iag idatsmuluns blow E.L, DISEASE- POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS / LOCATIONS./ vellicles l EXCLUSIONS ADDED EY ENDORSEMENT! SPECIAL PROVISIONS ADDITIONAL INSUREDS: CITY OF SAN DIEGO, ITS RESPECTIVE ELECTED OFFICIALS, OFFICERS,EMPLOYEES, AGENTS AND REPRESENTATIVES, AS AN ADDITIONAL, INSURED. col POLICY IS PRIMARY AND NON-CONTRIBUTORY -CERTIFICATE HOLDER THE CITY OF SAN DIEGO REALESTATE ASSE.RS RD AVE., SUITE 1700-M SAN DIEGO, CA CANCELLATION' SHOULD ANY OF THE ABOVE DEscRiseo nuoin SE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, TIIE ISSUING INSURER WILL ENDEAVOR TO mati, 30 DAYS Iii:IRITTLIN Noma TO THE CERT-INC/OM HOLDER- NAMED TO THE LEFT, BUT milune TO DO SO SHALL impose Na boutuvrton ort LIABILITY OP ANY KIND UPON THE INSURER, ITS AGENTS OR. REPRESEN TIVES.

2 Sep :30PM HP Fax 4thdistrict SenioR page 1 iaok To Forms Listing POLICY NUMBER, 2D NPO COMMEFICIAL. NERAL LIAIRIUTY CO This a Tf11.$. ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY., ADDITIONAL INSURED- DESIGNATED PERSON OR ORGANIZATION emit modifies insurancs,provided under the loliboing, totial itt,nval LlAgilLiTY.COVgriAd PAM 5W141:itIM."City Of an tsgo 1itptiebtat J offldlais,.offisara-, '01-ployees,. aents. and.repreaeritativ -AdditiOnat irisiged, COL P011oy is Primary arid Nbri4Porttribbtory, Any pooh Or Organization that you are required to add as ati additional insured on this policy under.writteitoontraot Or agreement currently : in affect, or booorning effective during the term of this pollq, or mob.* cortifloate of insurance 'naming such person or organization as additional insured has been issued, but only With repectto their liability arising out Of thv.requirernerits for certain performance : placed upon you, oa O nonprofit brgarilzotion, in consideration for funding or financial contributions you reb100..from'thern, The iadditional insured status Will not be afforded with respect to liability arising out of or related to your activities as a real estate Manager for that person or organization. a an ii Mt- tsove-1 bø.$iowrr in- W41* 10 Att - Ituti,ured Is amende4 to in-. iøa a an additional insured the -potion(*) Or orgarii, litlOoKliiiown in- the cheduta riun only with respect 10 lltnitty Ion 'bodily -injury", ":PM.PerlY ciarhage 00%0 and advertising injury" paused, in Who) or part, by your sots opotiii.sion't or the acts or -Siorit of ifioso ab'fino yo4r kaehail:.16..tha.psiiorenonoeo our-ono:110g operetiem: or ih 'POPtsoiInti with your.prentises owned by or MAW fdyou. ISOPM04"

3 Sep :50PM HP Fax 4thdistrict SenioR page 1 DECLARATION OF CONTRACTOR RE: AUTOMOBILE INSURANCE COVERAGE, Regarding the FY 2014 Agreement [Agreement] u etween th? City of S Diego, a municipal corporation [City] and ontractorl, Contractor declares as follows: 1. Contractor does not currently own any vehicles; 2. Contractor has obtained, and shall maintain during the term of the Agreement, automobile insurance coverage for "hired autos" and "non-owned autos"; and 3. In the event Contractor subsequently acquires any vehicle(s) during the term of the Agreement, the Contractor shall immediately obtain, and provide to the City the required evidence of, automobile insurance coverage for "any auto," as required in Section 12.4 of the Agreement. For the purpose of this Declaration, automobile insurance coverage for "any auto," "hired autos," and "non-owned autos" are defined as follows: Any Auto: Coverage is provided for any auto, including autos owned by the insured, autos the named insured hires or borrows from others, and other non-owned autos used in theinsured's business. Hired Autos: Coverage is provided only for autos leased, hired, rented, or borrowed for use in the named insured's business. Non-Owned Autos: Coverage is provided only for autos not owned, leased, hired, or borrowed by the named insured. Coverage includes autos owned by the insured's employees or members of their households, but only while used in the named insured's business or personal affairs.

4 STATE COMPENSATION INSURANCE FUND ISSUE DATE: P.O. BOX , SAN FRANCISCO,CA CERTIFICATE OF WORKERS' COMPENSATION INSURANCE POLICYHOLDER COPY GROUP: POLICY NUMBER: CERTIFICATE ID: 8 CERTIFICATE EXPIRES: / SD CITY OF SAN DIEGO RD AVE STE 1400 SAN DIEGO CA SD This is to certify that we have issued a valid Workers Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon 10 days advance written notice to the employer. We will also give you 10 days advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy. Authorized Representative 'finja40.. F President and CEO EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE IS ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: CITY OF SAN DIEGO 0.4. n n EMPLOYER FOURTH DISTRICT SENIORS RESOURCE CENTER (A NON-PROFIT CORPORATION) 570 S 65TH ST SAN DIEGO CA (REV ) [ARH,CNI PRINTED :

5 WAIVER OF SUBROGATION NOTICE Enclosed is your copy of a certificate of insurance on which the certificate holder required a waiver of subrogation.: 1. Please be advised that a waiver of subrogation requires that a 3% surcharge - will be applied by State Fund ONLY to the premium assessed on the payroll of your employees earned while engaged in work for that certificate holder who requested the waiver. (Note: if you have no employee payroll on that job, then there is no charge.) 2. To apply the 3% surcharge, you must also agree to maintain accurately segregated payroll records for employees engaged in work on job/s for the certificate holder who has the waiver. The payroll records are subject to verification by an auditor. Example: Payroll for job: Sample Rate: Regular Premium equals: Surcharge: Additional Waiver charge: Total premium equals $5, % $ % $ $ ( )

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