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Francine R. Digitally signed by Francine R.
<br />Villareal
<br />Villareal Date- 021.08.1712:24:57-07'00'
<br />JLEEENG-01 MICHAELA
<br />,d►coRO CERTIFICATE OF LIABILITY INSURANCE
<br />DATE(MM/DD/YYYY)
<br />8/10/2021
<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 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 License # OE67768
<br />CONTACT Glgii Yuen
<br />PHONE FAX
<br />(A/C, No, Ext): (925) 660-3514 50008 (A/C, No):(925) 416-7869
<br />IOA Insurance Services
<br />3875 Ho yard Road
<br />Suite 2O
<br />E-MAIL Y I Gi uen@ioausa.com
<br />ADDRESS: Gigi-Yuen@ioausa.com
<br />Pleasanton, CA 94588
<br />INSURERS AFFORDING COVERAGE
<br />NAIC #
<br />INSURER A : Travelers Property Casualty Company of America
<br />25674
<br />INSURED
<br />INSURER B: Arch Insurance Company
<br />11150
<br />INSURER C:
<br />JLee Engineering, Inc.
<br />INSURER D 7
<br />430 S. Garfield Avenue, #301
<br />Alhambra, CA 91801
<br />INSURER E
<br />INSURER F :
<br />COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
<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 />INSD
<br />SUBR
<br />WVD
<br />POLICY NUMBER
<br />POLICY EFF
<br />MM/DD/YYYY
<br />POLICY EXP
<br />MM/DD/YYYY
<br />LIMITS
<br />A
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />EACH OCCURRENCE
<br />$ 2,000,000
<br />CLAIMS -MADE j OCCUR
<br />6802HO13864
<br />9/1/2021
<br />9/1/2022
<br />DAMES Ea occAGE TO RENTED
<br />PREMISurrence
<br />1,000,000
<br />$
<br />MED EXP (Any oneperson)
<br />$ 10,000
<br />PERSONAL & ADV INJURY
<br />$ 2,000,000
<br />GENT
<br />AGGREGATE LIMIT APPLIES PER:
<br />GENERAL AGGREGATE
<br />$ 4,000,000
<br />POLICY X71 PEA LOC
<br />PRODUCTS - COMP/OP AGG
<br />$ 4,000,000
<br />$
<br />OTHER:
<br />A
<br />AUTOMOBILE
<br />LIABILITY
<br />COMBINED SINGLE LIMIT
<br />Ea accident
<br />2,000,000
<br />$
<br />BODILY INJURY Perperson)
<br />$
<br />ANY AUTO
<br />6802HO13864
<br />9/1/2021
<br />9/1/2022
<br />OWNED SCHEDULED
<br />AUTOS ONLY AUTOS
<br />BODILY INJURY Per accident
<br />$
<br />X
<br />PROPERTY DAMAGE
<br />ccident
<br />Per accident)
<br />$
<br />HIRED X NON -OWNED
<br />AUTOS ONLY AUTOS ONLY
<br />UMBRELLA LIAB
<br />OCCUR
<br />EACH OCCURRENCE
<br />$
<br />AGGREGATE
<br />$
<br />EXCESS LIAB
<br />CLAIMS -MADE
<br />DED RETENTION $
<br />$
<br />A
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY
<br />Y/N
<br />R/EXECUTIVE ❑
<br />ANY PROPRIETOR/ EXCLUDED?
<br />OF EXCLUDED?
<br />(Mandatory in NH)
<br />N/A A
<br />UB3J84391A
<br />9/1/2021
<br />9/1/2022
<br />X PER
<br />STATUTE EERR
<br />E.L. EACH ACCIDENT
<br />1,000,000
<br />$
<br />E.L. DISEASE - EA EMPLOYEE
<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 />B
<br />Professional Liab.
<br />PAAEP00102503
<br />9/1/2021
<br />9/1/2022
<br />Per Claim
<br />1,000,000
<br />B
<br />Professional Liab.
<br />PAAEP00102503
<br />9/1/2021
<br />9/1/2022
<br />Aggregate
<br />2,000,000
<br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
<br />All Operations of the Named Insured.
<br />General Liability: See Additional Insured Endorsement attached; such coverage is Primary & Non -Contributory and includes Separation of Insureds, as
<br />required per written contract.
<br />NOTE: No company -owned vehicles. General Liablity includes coverage for Hired & Non -Owned Auto Liability.
<br />GENERAL LIABILITY ADDITIONAL INSURED INCLUDES THE FOLLOWING PERSON(S) OR ORGANIZATION(S): City of Santa Ana, its officers, employees, and
<br />authorized agents
<br />CANCELLATION NOTICE: 30 days written notice is provided to the aforementioned Certificate Holder.
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />THE EXPIRATION DATE THEREOF,
<br />NOTICE WILL BE DELIVERED IN
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />City of Santa Ana
<br />AUTHORIZED REPRESENTATIVE
<br />Risk Management Division
<br />20 Civic Center Plaza, 4th Floor
<br />�i���
<br />oRaN a
<br />RiskManaganentDivisian
<br />REVIEWED &APPROVED BY.
<br />Santa Ana CA 92701
<br />F P1. vj&441d
<br />ACORD 25 (2016/03)
<br />©1988-2015 ACORD C
<br />The ACORD name and logo are registered marks of ACORD
<br />Risk Management Analyst
<br />
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