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T01 I 1 Jerson Digitally signed :Pierson
<br />Date: 2021.12.14 09:0809:08:32
<br />-08,00,
<br />C W E0000-01 RDEAN DA
<br />ACO'Rv CERTIFICATE OF LIABILITY INSURANCE
<br />DAT2/3/2D/Y1
<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 # 0757776
<br />CONTACT Irene Laine
<br />NAME:
<br />PHONE �� , No):(951) 231-2572
<br />(A/C, No, Ext): (714) 739-3184
<br />HUB International Insurance Services Inc.
<br />6 Centerpointe Drive
<br />Suite 350
<br />E-MAILcal.cpu@hubinternational.com
<br />La Palma, CA 90623
<br />INSURERS AFFORDING COVERAGE
<br />NAIC #
<br />INSURER A: Crum & Forster Specialty Insurance Company
<br />44520
<br />INSURED
<br />INSURER B: West American Insurance Co
<br />44393
<br />CWE
<br />INSURER C: State Compensation Insurance Fund of California
<br />35076
<br />1561 E. Orangethorpe Avenue
<br />Suite 240
<br />INSURER D :
<br />INSURER E :
<br />Fullerton, CA 92831
<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/DDIYYYY
<br />LIMITS
<br />A
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />EACH OCCURRENCE
<br />$ 2,000,000
<br />71
<br />CLAIMS -MADE X OCCUR
<br />X
<br />X
<br />EPK-137943
<br />12/8/2021
<br />12/8/2022
<br />DAMAGE TO RENTED
<br />PREMISES Ea occurrence
<br />100,000
<br />$
<br />MED EXP (Any oneperson)
<br />$ 10,000
<br />PERSONAL & ADV INJURY
<br />$ 2,000,000
<br />GEN'L
<br />AGGREGATE LIMIT APPLIES PER:
<br />GENERAL AGGREGATE
<br />$ 4,000,000
<br />POLICY � JECT1:1 LOC
<br />PRODUCTS - COMP/OP AGG
<br />$ 4,000,000
<br />$
<br />OTHER:
<br />B
<br />AUTOMOBILE LIABILITY
<br />COMBINED SINGLE LIMIT
<br />Ea accident
<br />1,000,000
<br />$
<br />BODILY INJURY Perperson)
<br />$
<br />X ANY AUTO
<br />X
<br />BAW57609336
<br />12/8/2021
<br />12/$/2022
<br />OWNED SCHEDULED
<br />AUTOS ONLY AUTOS
<br />BODILY INJURY Per accident
<br />$
<br />PROPERTY DAMAGE
<br />Per accident
<br />$
<br />HIRED NON -OWNED
<br />AUTOS ONLY AUTOS ONLY
<br />A
<br />UMBRELLA LIAB
<br />X
<br />OCCUR
<br />EACH OCCURRENCE
<br />$ 1,000,000
<br />X
<br />EXCESS LIAB
<br />CLAIMS -MADE
<br />EFX-119354
<br />12/8/2021
<br />12/8/2022
<br />AGGREGATE
<br />$ 1,000,000
<br />DED RETENTION $
<br />$
<br />C
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY
<br />ANY PROPRIETOR/PARTNER/EXECUTIVE Y
<br />OFFICER/MEMBER EXCLUDED? Ll
<br />(Mandatory in NH)
<br />N / A
<br />X
<br />9170147-21
<br />12/1 /2021
<br />12/1 /2022
<br />X PER OTH-
<br />STATUTE ER
<br />E.L. EACH ACCIDENT
<br />$ 1,000,000
<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 />A
<br />Professional Liab
<br />EPK-137943
<br />12/8/2021
<br />12/8/2022
<br />Each Wrongful Act
<br />2,000,000
<br />A
<br />Professional Liab
<br />EPK-137943
<br />12/8/2021
<br />12/8/2022
<br />Aggregate
<br />4,000,000
<br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
<br />RE: Project Name: RFP 20-102.
<br />The City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California 92701; officers, agents, employees, representatives and volunteers are Additional Insured
<br />with regard to General Liability when required by written contract per the attached endorsement forms EN0111 02/11 and EN0147 11/11, Primary &
<br />Non -Contributory and Waiver of Subrogation included. Per project aggregate applies to General Liability per the attached endorsement form EN0301 09/14.
<br />Additional Insured with regard to Auto Liability when required by written contract per the attached endorsement form AC8543 06/18. Waiver of Subrogation
<br />with regard to Workers Compensation applies when required by written contract per the attached endorsement form 2572.
<br />City of Santa Ana
<br />Risk Management Division
<br />20 Civic Center Plaza
<br />Santa Ana, CA 92702
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />ACCORDANCE WITH THE POLICY PROVE"" -
<br />AUTHORIZED REPRESENTATIVE / REvEwEc, & APPRCWED By.
<br />_ .""_.' Risk Manag,meit CYen-I Aide
<br />ACORD 25 (2016/03) © 1988-2015 ACORD CC �' "`N
<br />The ACORD name and logo are registered marks of ACORD
<br />
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