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Francine R. Digitally signed by Francine R.
<br />Villareal
<br />Villareal Date: 2021.06.2217:18:15-07'00'
<br />4LEAINC-01 MINED1
<br />ACORO
<br />�� CERTIFICATE OF LIABILITY INSURANCE
<br />FDA�TE(MMIDDlYYYY)
<br />6/22/2021
<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 # OC41366
<br />Granite Professional Insurance Brokerage, Inc.
<br />360 Lindbergh Avenue
<br />Livermore, CA 94661
<br />CONTACT
<br />NAME:
<br />PHONE 925 462-8400 FAX 925 462-8888
<br />(A/C, No, Ext): ( ) (A/c, No):( )
<br />ADDRIESS, commercial@graniteins.com
<br />INSURERS AFFORDING COVERAGE
<br />NAIC #
<br />INSURER A: Travelers Property Casualty Company of America
<br />25674
<br />INSURED
<br />INSURER B : Travelers Indemnity Company of Connecticut
<br />25682
<br />INSURER C : Redwood Fire & Casualty Insurance Company
<br />11673
<br />4LEAF, Inc.
<br />INSURER D: Evanston Insurance
<br />35378
<br />2126 Rheem Dr
<br />Pleasanton, CA 94688
<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 />MMIDD/YYYY
<br />POLICY EXP
<br />MMIDD/YYYY
<br />LIMITS
<br />A
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />EACH OCCURRENCE
<br />$ 1,000,000
<br />CLAIMS -MADE X OCCUR
<br />X
<br />X
<br />6$DD,J26$]20
<br />4/9/2021
<br />4/9/2022
<br />DAMAGE TO RENTED
<br />PREMISES Ea occurrence
<br />1,000,000
<br />$
<br />MED EXP (Any oneperson)
<br />$ 5,000
<br />PERSONAL & ADV INJURY
<br />$ 1,000,000
<br />GEN'L
<br />AGGREGATE LIMIT APPLIES PER:
<br />GENERAL AGGREGATE
<br />$ 2,000,000
<br />POLICY � JECT El LOC
<br />PRODUCTS - COMP/OP AGG
<br />$ 2,000,000
<br />$
<br />OTHER:
<br />B
<br />AUTOMOBILE
<br />LIABILITY
<br />COMBINED SINGLE LIMIT
<br />Ea accident
<br />1,000,000
<br />$
<br />X
<br />BODILY INJURY Perperson)
<br />$
<br />ANY AUTO
<br />X
<br />X
<br />8107RO26623
<br />4/9/2021
<br />4/9/2022
<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 />A
<br />X
<br />UMBRELLA LIAB
<br />X
<br />OCCUR
<br />EACH OCCURRENCE
<br />$ 6,000,000
<br />EXCESS LIAB
<br />CLAIMS -MADE
<br />CUP1S364055
<br />4/9/2021
<br />4/9/2022
<br />AGGREGATE
<br />$ 6,000,000
<br />DED RETENTION $
<br />$
<br />C
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY
<br />YIN
<br />ANY PROPRIETOR/PARTNER/EXECUTIVE ❑
<br />OFFICER/MEMBER EXCLUDED?
<br />/M
<br />(Mandatory in NH)
<br />NIA
<br />X
<br />FOWC216539
<br />4/9/2021
<br />4/9/2022
<br />X PER OTH-
<br />STATUTE ER
<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 />D
<br />Professional Liab
<br />MKLV7PL0004668
<br />4/9/2021
<br />4/9/2022
<br />Each Claim
<br />2,000,000
<br />D
<br />Professional Liab
<br />MKLV7PL0004668
<br />4/9/2021
<br />4/9/2022
<br />Aggregate
<br />2,000,000
<br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
<br />All operations of the named insured. Certificate holder is named as additional insured to General Liability and Automobile Liability policies per attached
<br />endorsements CG D3 81 09 15 and CA T3 53 02 15. Waiver of Subrogation applies to General Liability per endorsement CG D3 81 09 15. Waiver of Subrogation
<br />applies to Auto Liability per endorsement CA T3 53 02 15.
<br />City of Santa Ana, its officers, employees, agents and representatives are Additional Insured on General Liability policy and Automobile Liability policy per
<br />attached endorsements CG D3 81 09 15 and CA T3 53 02 15. General Liability is Primary and Non -Contributory per Form CG D3 81 09 15. Waivers of
<br />Subrogation apply to General Liability, Automobile Liability and Workers Compensation Policy per attached endorsements CG D3 81 09 15, CA T3 53 02 15
<br />and WC 99 04 10 C. 30 Day Notice of Cancellation applies on Workers' Compensation and General Liability policies.
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />City of Santa Ana
<br />Y
<br />THE EXPIRATION DATE THEREOF,
<br />NOTICE WILL BE DELIVERED IN
<br />Risk Management Division
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />20 Civic Center Plaza, 4th Floor
<br />Santa Ana, CA 92701
<br />AUTHORIZED REPRESENTATIVE
<br />RisieMatlagementDiviaian
<br />,�oRaN�
<br />REVIEWED & APPROVED BY.-
<br />a
<br />r
<br />v�
<br />ACORD 25 2016/03
<br />( )
<br />(D 1988-2015 ACORD C
<br />The ACORD name and logo are registered marks of ACORD
<br />Risk Management Analyst
<br />
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