|
AICA' CERTIFICATE OF LIABILITY INSURANCE
<br />6
<br />DATE(MMIDDITYYY)
<br />11/09/2018
<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(les) must have ADDITIONAL INSURED provisions or be endorsed.
<br />If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
<br />this certificate does not confer rights to the certificate holder In lieu of such Endorsement(s).
<br />PRODUCER
<br />Partes Insurance Associates, Inc.
<br />PTL Insurance Brokers, Inc.
<br />CONTACT
<br />NAME: Richard Pedevillano
<br />PRo ONE (626) 967-9581 LA No): (626) 967-1664
<br />EXIT
<br />P.O. Box 4155
<br />Covina CA 91723
<br />JAI
<br />DP ESS: certificates® tlinsurance.com
<br />INS U RI A FFORDING COVE RAG E NAICk
<br />Y
<br />INSURER A: Ohio Security Insurance Co. 34082
<br />11/15/201511/15/2019
<br />INSURED (714) 879-5000
<br />BDL Caren & Cons
<br />INSURER B: American Fire & Casualty Co. 24066
<br />INSURER C: Twin City Fire Insurance Co. 29459
<br />120 S. State College Blvd.
<br />INSURER D:
<br />Suite #200
<br />Brea, CA 92821
<br />NSURERE :
<br />IN URERF:
<br />C0VFRA1;FS r.FRTIFICATF NHMRl=IZ .h Tri 61RA OC\ACIn PI MillUlp CR•
<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 />ADOL
<br />SUER
<br />POLICYNUMBER
<br />POLICY EFF
<br />MMIDDfrYVYI
<br />POLICY EXP
<br />(MMIDOMM
<br />LIMITS
<br />A
<br />X COMMERCIAL GENERAL LIABILITY
<br />CLAIMS -MADE �X OCCUR
<br />Y
<br />Y
<br />HZ556380327
<br />11/15/201511/15/2019
<br />EACH OCCURRENCE $ 2,000,000
<br />PREMISES Be occurrence) $ 21000,000
<br />MED EXP (Any one person $ 15,000
<br />PERSONAL&ADV INJURY S Included
<br />GEN'L AGGREGATE LIMIT APPLIES PER
<br />GENERAL AGGREGATE S 4,000,000
<br />X POLICY ❑ PRO- [_]LOC
<br />NECT
<br />PRODUCTS -COMPIOPAGG $ 4,000,000
<br />$
<br />OTHER:
<br />i
<br />I
<br />AUTOMOBILE
<br />LIABILITY
<br />COMBINED SINGLE LIMIT
<br />Ea accident$ 1,000,000
<br />BODILY INJURY (Per person) $
<br />A
<br />ANY AUTO
<br />y
<br />y
<br />BAS(19)56380327
<br />11/ 15/2018
<br />11/ 15 /2 019
<br />OWNED SCI IEDULED
<br />AUTOS ONLY AUTOS
<br />GOD ILY INJURY (Per accident)8
<br />X
<br />:HIRED NON-OWNEDPROPERTY
<br />AUTOS ONLY X AUTOS ONLY
<br />DAMAGE
<br />Par accident S
<br />B
<br />X
<br />UMBRELLA LIARX
<br />OCCUR
<br />USA(19)56380327
<br />11/15/2018
<br />11/15/2019
<br />EACH OCCURRENCE $ 11000,000
<br />AGGREGATE $ 1,000,000
<br />EXCESS LIAR
<br />CLAIMS -MADE
<br />DEO I X I RETENTIONS 10,000
<br />Prod -Comp Dos S 1,000,000
<br />A
<br />WORKERSCORS'LIATIONILIT YIN
<br />AND EMPLOYERS' LIABILITY
<br />Y
<br />XWS(19)56300327
<br />11/15/2018
<br />11/15/2019
<br />X STATUTE OERH
<br />EL EACH ACCIDENT $ 1,000,000
<br />ANYPROPRIETORIPARTNERIEXECUTIVE
<br />OFFICER/MEMBER EXCLUDED? ❑ 'NIA
<br />E. L. DISEASE - EA EMPLOYEE $ 1,000,000
<br />(Mandatory In NH)
<br />If ye s, descnbe antler
<br />DESCRIPTION OF OPERATIONS below
<br />E, L. DISEASE -POLICY LIMIT ,$ 1,000,000
<br />C
<br />Professional Liability
<br />72PG0260349
<br />11/15/2016
<br />11/15/2019
<br />Each Claim $ 1,000,000
<br />Aggregate i$ 2,000,000
<br />DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached If more space Is requ(red)
<br />The City of Santa Ana, its officers, employees and agents are named Additional Insured with primary
<br />& noncontributory wording and Waiver of Subrogation applies per End. attached with regard to
<br />General Liability policy.
<br />With regard to Auto Liability policy, Additional Insured and Waiver of Subrogation End. is attached.
<br />With regard to Workers' Compensation policy, Waiver of Subrogation End. is attached.
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />City of Santa Anann
<br />ACCORDANCE WITH THE POLICY PROVISIONS,
<br />P.O. Box 1964 �• AUTHORIZED REPRESENTATIVE
<br />2121 z-0
<br />Santa Ana CA 92702 9N�.,,� / / d '�'..��F�e-L,_a�% �•
<br />ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
<br />Page 1 of 1
<br />
|