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Digil
<br />Tori Pierson Date: 210021gnedb08:55:35e0800'
<br />BIGBENC-01 KGOAD
<br />ACORO°° CERTIFICATE OF LIABILITY INSURANCE
<br />DATE(MMIDDIYYYY)
<br />11/17/2021
<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 # 0M70471
<br />Orion Risk Management Insurance Services, An Alera Group Insurance
<br />Agency, LLC
<br />1800 Quail Street, Suite 110
<br />CONTACT Kennail Goad
<br />NAME:
<br />PHONE FAX
<br />(A/C, No, Ext): (949 ) 284-6044 (A/C, No):
<br />E-MAILkgoad@orionrisk.com
<br />Newport Beach, CA 92660
<br />INSURER S AFFORDING COVERAGE
<br />NAIC #
<br />INSURERA:Starr Surplus Lines Ins. Co.
<br />13604
<br />INSURED
<br />INSURER B:Depositors Insurance Company
<br />42587
<br />INSURER C: Nationwide Mutual Insurance Company
<br />23787
<br />Big Ben, Inc.
<br />INSURER D : *Travelers Property Casualty Company of America
<br />25674
<br />4790 Irvine Blvd. #105-404
<br />Irvine, CA 92620
<br />INSURER E
<br />INSURER F :
<br />COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 2
<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 />1000066896211
<br />4/5/2021
<br />4/5/2022
<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 />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 />ACPBA3100136937
<br />7/1/2021
<br />7/1/2022
<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 />$ 4,000,000
<br />X
<br />EXCESS LIAB
<br />CLAIMS -MADE
<br />1000337276211
<br />4/5/2021
<br />4/5/2022
<br />AGGREGATE
<br />$ 4,000,000
<br />DED RETENTION $
<br />$
<br />C
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY
<br />YIN
<br />ANY PROPRIETOR/PARTNEXECUTIVE
<br />OFFICER/MEMBER EXCLUDEDE D?
<br />(Mandatory in NH)
<br />NIA
<br />X
<br />ACPWC3100135937
<br />7/1/2021
<br />7/1/2022
<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 />A
<br />Pollution Liability
<br />1000066896211
<br />4/5/2021
<br />4/5/2022
<br />Each Claim
<br />1,000,000
<br />D
<br />Equipment Floater
<br />6607NO92607TIL21
<br />4/5/2021
<br />4/5/2022
<br />Rented/Leased Equip
<br />160,000
<br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
<br />City of Santa Ana, its officers, employees, agents and representatives are Additional Insureds with respect is named as additional insured when required by
<br />written contract per the attached auto and General Liability endorsement.
<br />Primary and noncontributory coverage applies when required by written contract per the attached General Liability endorsement.
<br />Waiver of Subrogation applies per the terms of the attached Automobile Liability and Workers' Compensation endorsements and General Liability
<br />endorsement.
<br />SEE ATTACHED ACORD 101
<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 PROV._._.
<br />AUTHORIZED REPRESENTATIVE E S&APPRavEDft.
<br />CC '�.
<br />'!.,m' ,«,•." .:nRisls Mana9enxirACleriralAicRe
<br />ACORD 25 (2016/03) ©1988-2015 ACORD C( 61!"
<br />The ACORD name and logo are registered marks of ACORD
<br />
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