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AngiFDigitally signed
<br />R&PE-'1 SIAMMANR
<br />(M D / YY)
<br />'y AngM.092/1822
<br />ACORO"° CERTIFICATE OF LIABILITY I SURANCE
<br />�.....--�' AA Date: 2
<br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CON FM UsIgg"gummR. THIS
<br />CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVE'tAGE 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 Glgl 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 20
<br />E-MAIL Gigi.Yuen@ioausa.com
<br />Gi Yuen^
<br />ADDRESS: g
<br />Pleasanton, CA 94588
<br />INSURERS AFFORDING COVERAGE
<br />NAIC #
<br />INSURERA: RLI Insurance Company
<br />13056
<br />INSURED
<br />INSURERB: Hartford Casualty Insurance Company
<br />29424
<br />Fehr & Peers
<br />INSURERC: Liberty Surplus Insurance Corp10725
<br />101 Pacifica
<br />Suite 300
<br />INSURER D :
<br />INSURER E :
<br />Irvine, CA 92618
<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 />$ 2,000,000
<br />CLAIMS -MADE j OCCUR
<br />PSB0006683
<br />12/6/2021
<br />12/6/2022
<br />DAMAGE TO RENTED
<br />PREMISES Ea occurrence
<br />1,000,000
<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 X71 JECT El LOC
<br />PRODUCTS - COMP/OPAGG
<br />$ 4,000,000
<br />$
<br />OTHER:
<br />A
<br />AUTOMOBILE
<br />LIABILITY
<br />COMBINED SINGLE LIMIT
<br />Ea accident
<br />1,000,000
<br />$
<br />BODILY INJURY Perperson)
<br />$
<br />ANY AUTO
<br />PSA0002276
<br />12/6/2021
<br />12/6/2022
<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 />A
<br />UMBRELLA LIAB
<br />X
<br />OCCUR
<br />EACH OCCURRENCE
<br />$ 5,000,000
<br />X
<br />EXCESS LIAB
<br />CLAIMS -MADE
<br />PSE0002889
<br />12/6/2021
<br />12/6/2022
<br />AGGREGATE
<br />$ 5,000,000
<br />DED RETENTION $
<br />$
<br />B
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY
<br />Y/N
<br />ANY PROPRIETOR/PARTNER/EXECUTIVE ❑
<br />OFFICER/MEMBER EXCLUDED?
<br />(Mandatory in NH)
<br />N/A
<br />57WEGZJ1989
<br />5/1/2022
<br />5/1/2023
<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 />C
<br />Professional Liab.
<br />AEXNYABEFJ2006
<br />12/6/2021
<br />12/6/2022
<br />Per Claim
<br />5,000,000
<br />C
<br />Professional Liab.
<br />AEXNYABEFJ2006
<br />12/6/2021
<br />12/6/2022
<br />Aggregate
<br />5,000,000
<br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
<br />Project Number / Name: OC19STAN.00/.01 Santa Ana On- Call
<br />All Operations of the Named Insured, including the aforementioned project.
<br />General Liability: Please see blanket Additional Insured endorsement attached; such coverage is Primary and Non -Contributory with Waiver of Subrogation
<br />included, as required per written contract.
<br />Auto Liability: No company owned vehicles. Please see blanket Additional Insured endorsement with Waiver of Subrogation included, as required per written
<br />contract.
<br />Workers' Compensation: Waiver of Subrogation is included as per attached blanket Waiver of Subrogation endorsement, as required per written contract.
<br />SEE ATTACHED ACORD 101
<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 PROVISIONS.
<br />City of Santa Ana AUTHORIZED REPRESENTATIVE
<br />Risk Management Division Risk kluagment DlMslan
<br />20 Civic Center Plaza w '"_ - ;i REVIEWED & APPROVED BY. -
<br />Santa Ana CA 92701 0:
<br />ACORD 25 (2016/03) © 1988-2015 ACORD I 4 e Aeevulo
<br />The ACORD name and logo are registered marks of ACORD Risk Management specialist
<br />
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