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<br />A� Q►2� CERTIFICATE OF LIABILITY INSURANCE
<br />DATE (MMIDDNYYY)
<br />01/27/2012
<br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
<br />CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER. THE COVERAGE AFFORDED BY THE POLICIES
<br />BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
<br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
<br />IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
<br />the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
<br />ce rtificate ho lder in lieu of such endorsement(s).
<br />PRODUCER
<br />Marsh USA Inc
<br />2405 Grand Boulevard, #900
<br />CONTACT
<br />NAME:
<br />PHONE FAX No):
<br />E - MAIL
<br />ADDRESS:
<br />Kansas City, MC 64108
<br />Attn: KansasCity .Certrequest @marsh.com Fax: 212 -948 -0015
<br />HDOG25528839
<br />APPROVED AS
<br />INSURER (S) AFFORDING COVERAGE
<br />NAIC #
<br />INSURER A : ACE American Insurance Company
<br />22667
<br />081623- 001 - Corp -11 -12 Rivers 376913 4934 3575
<br />INSURED
<br />H&R Block, Inc.
<br />One H&R Block Way
<br />INSURER B : National Union Fire Ins Co Pittsburgh PA
<br />19445
<br />INSURER C : Indemnity Ins Co Of North America
<br />43575
<br />INSURER D : Axi Insurance Company
<br />37273
<br />Kansas City, MG 64105
<br />INSURER E:
<br />PERSONAL & ADV INJURY
<br />INSURER F:
<br />COVERAGES CERTIFICATE NUMBER: CHI - 004376913 - 02 REVISION NUMBER:2
<br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
<br />INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
<br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
<br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
<br />INSR
<br />LTR
<br />TYPE OF INSURANCE
<br />ADDL
<br />5UBR
<br />WV
<br />POLICY NUMBER
<br />fMM1DDIYYYY
<br />MM1DDlYYYY
<br />LIMITS
<br />A
<br />GENERAL LIABILITY
<br />x COMMERCIAL GENERAL LIABILITY
<br />HDOG25528839
<br />APPROVED AS
<br />0510112011
<br />TO
<br />05101
<br />RM
<br />EACH OCCURRENCE
<br />$ 2,000,000
<br />DAMAGE TO RENTED
<br />PREMISES Ea occurrence
<br />$ 1}000,000
<br />MED EXP (Any one person)
<br />$ NIA
<br />CLAIMS -MADE I X i OCCUR
<br />PERSONAL & ADV INJURY
<br />$ 2,000,000
<br />GENERAL AGGREGATE
<br />$ 10,000,000
<br />PRODUCTS - COMP/OP AGG
<br />$ 2,000,000
<br />GEN'L AGGREGATE LIMIT APPLIES PER
<br />PRO-
<br />X POLICY LOC
<br />Risk M
<br />ager
<br />$
<br />A
<br />AUTOMOBILE LIABILITY
<br />ISA H08634464
<br />0510112011
<br />0510112012
<br />COMBINED SINGLE LIMIT
<br />Ea accident
<br />2,000,000
<br />BODILY INJURY (Per person)
<br />$
<br />X ANY AUTO
<br />BODILY INJURY (Per accident)
<br />$
<br />ALL OWNED SCHEDULED
<br />AUTOS AUTOS
<br />PROPERTY DAMAGE
<br />Per accident
<br />$
<br />NON -OWNED
<br />HIRED AUTOS AUTOS
<br />B
<br />X
<br />UMBRELLA LIAR
<br />X
<br />OCCUR
<br />BE 9974983
<br />05101/2011
<br />0510112012
<br />EACH OCCURRENCE
<br />$ 5,000,000
<br />AGGREGATE
<br />$ 5,000 ,000
<br />EXCESS LIAB
<br />CLAIMS -MADE
<br />DIED RETENTION $
<br />$
<br />A
<br />WORKERS COMPENSATION
<br />WLR C46479610 (CA, AZ 8 MA)
<br />0510112011
<br />0510112012
<br />X I WC STATU- OTH-
<br />C
<br />C
<br />AND EMPLOYERS' LIABILITY YIN
<br />ANY PROP RIETORIPARTNERIEXECUTIVE
<br />OFFICER/MEMBER EXCLUDED?
<br />(Mandatory in NH)
<br />NIA
<br />WLR C46479634 (AOS)
<br />RWC C46479622 I, ME 8 OR)
<br />05101/2011
<br />0510112011
<br />0510112012
<br />0510112012
<br />E.L. EACH ACCIDENT
<br />1,000,000
<br />$
<br />E.L. DISEASE - EA EMPLOYE
<br />$ 1,000,000
<br />If yes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />E.L. DISEASE - POLICY LIMIT
<br />1,000,000
<br />$
<br />D
<br />Property
<br />MCB726493 -11
<br />0510112011
<br />0510112012
<br />Blanket Limit, All Risk $100,000,000
<br />Replacement Cost
<br />DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required)
<br />Office: La Sierra Plaza, 3834 -3836 La Sierra Ave., Riverside, CA 92505
<br />e: Chinese New Year Lunar Festival event on Saturday, 1/28112
<br />ity of Riverside, Christina Garcia, Shanee' Arceneaux, Anthony Rodriguez, Mark Miller, Carlos, and Jaycee are named as Additional Insured if required to be so by written contract. Coverage shown is primary and
<br />I n- contributory if required to be so by written contract. Waiver of Subrogation is granted if required to be so by written contract.
<br />CERTIFICATE HOLDER CANCELLATION
<br />City of Riverside
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />Chinese New Year Lunar Festival
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />Attn: Theresa Birkett
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />1091 Crestbrook Drive
<br />Riverside, CA 92505
<br />AUTHORIZED REPRESENTATIVE
<br />of Marsh USA Inc.
<br />Keith A. Stiles
<br />@ 1988 -2010 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD
<br />
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