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Digitally signed by Francine R.
<br />Francine R. Villareal Villareal
<br />PALP, INC. Date: 2021.06.2309:0�tAWA
<br />,d►coRO CERTIFICATE OF LIABILITY INSURANCE
<br />DAT/1612D/Y
<br />616/2021
<br />1
<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
<br />CONTACT
<br />NAME:
<br />(A/CC,Nro, Ext): (949) 553-9800 FAX No):(949) 553-0670
<br />The Wooditch Company Insurance Services, Inc.
<br />1 Park Plaza, Suite 400
<br />Irvine, CA 92614
<br />A DD E-MAIL
<br />INSURERS AFFORDING COVERAGE
<br />NAIC #
<br />INSURERA: Executive Risk Indemnity,Inc.
<br />35181
<br />INSURED
<br />INSURER B : Federal Insurance Company
<br />20281
<br />INSURER 7
<br />Palp, Inc. DBA Excel Paving Company; GAP Equipment, LLC
<br />INSURER D7
<br />2230 Lemon Avenue
<br />Long Beach, CA 90806
<br />INSURER E
<br />INSURER F :
<br />COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 1
<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 />$ 1,000,000
<br />CLAIMS -MADE X OCCUR
<br />X
<br />X
<br />54310180
<br />6/1/2021
<br />6/1/2022
<br />DAMAGE TO RENTED
<br />PREMISES Ea occurrence
<br />100,000
<br />$
<br />MED EXP (Any oneperson)
<br />$ 5,000
<br />PERSONAL & ADV INJURY
<br />$ 1,000,000
<br />GENT
<br />AGGREGATE LIMIT APPLIES PER:
<br />GENERAL AGGREGATE
<br />$ 2,000,000
<br />POLICY X 71 PEA LOC
<br />PRODUCTS - COMP/OPAGG
<br />$ 2,000,000
<br />EMPLOYEE BENEFI
<br />$ 1,000,000
<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 />54310182
<br />6/1/2021
<br />6/1/2022
<br />OWNED SCHEDULED
<br />AUTOS ONLY AUTOS
<br />BODILY INJURY Per accident
<br />$
<br />X
<br />PROPERTY DAMAGE
<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 />B
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY
<br />ANY PROPRIETOR/ R/EXECUTIVE
<br />X
<br />54310181
<br />6/1/2021
<br />6/1 /2022
<br />X PER
<br />STATUTE EERR
<br />E.L. EACH ACCIDENT
<br />1,000,000
<br />$
<br />OF EXCLUDED?
<br />EXCLUDED? ❑
<br />(Mandatory in NH)
<br />N/A A
<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 />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
<br />RE: Excel Job #5770; Agreement #A-2020-245-04; RFP# 20-106, RFCA 12/1/2020, Item #09; On -Call Emergency Asphalt Concrete, Concrete and Storm Drain
<br />Repair Services. glaipwv/auaiwv/wcwv
<br />City of Santa Ana, its officers, employees, agents, volunteers and representatives are included as Additional Insureds as respects General Liability and Auto
<br />Liability per attached endorsements.
<br />This insurance shall apply as Primary and Non -Contributory per attached endorsement.
<br />Waiver of Subrogation for General Liability, Auto Liability and Workers' Compensation: See Attached Endorsements.
<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
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<br />APPROPVE
<br />REVIEWED &APPROVED BY.-
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<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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