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<br />Ejhjubmmz!tjhofe! <br />TOANDMO-01KKELLY <br />DATE (MM/DD/YYYY) <br />cz!Bohjf! <br />CERTIFICATE OF LIABILITY INSURANCE <br />Bohjf! <br />3/16/2022 <br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS <br />Bdfwfep! <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 />Ebuf;!3133/14/32! <br />Bdfwfep <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 />25;64;24!.18(11( <br />this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). <br />CONTACT <br />PRODUCER <br />NAME: <br />PHONEFAX <br />Rubin Insurance Agency, Inc. <br />(858) 457-5720 <br />(A/C, No, Ext):(A/C, No): <br />5075 Shoreham Place Suite 100 <br />E-MAIL <br />michael@rubininsurance.com <br />San Diego, CA 92122 <br />ADDRESS: <br />INSURER(S) AFFORDING COVERAGENAIC # <br />Accredited Surety and Casualty Company, Inc. <br />26379 <br />INSURER A : <br />INSURED <br />Golden Bear Insurance Co39861 <br />INSURER B : <br />Insurance Company of the West27847 <br />INSURER C : <br />Standard Enterprises Inc, Dba: To and Mo Towing <br />518 N Poinsettia St <br />INSURER D : <br />Santa Ana, CA 92701 <br />INSURER E : <br />INSURER F : <br />COVERAGESCERTIFICATE 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 />INSRADDLSUBRPOLICY EFFPOLICY EXP <br />TYPE OF INSURANCEPOLICY NUMBERLIMITS <br />LTRINSDWVD(MM/DD/YYYY)(MM/DD/YYYY) <br />1,000,000 <br />A <br />COMMERCIAL GENERAL LIABILITY <br />X <br />EACH OCCURRENCE$ <br />DAMAGE TO RENTED <br />100,000 <br />CLAIMS-MADEOCCUR <br />X <br />1-TTS-CA-19-01257312-006/1/20216/1/2022 <br />$ <br />PREMISES (Ea occurrence) <br />X <br />50,000 <br />MED EXP (Any one person)$ <br />1,000,000 <br />PERSONAL & ADV INJURY$ <br />2,000,000 <br />GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE$ <br />PRO- <br />2,000,000 <br />POLICYLOC <br />PRODUCTS - COMP/OP AGG$ <br />JECT <br />Ded0 <br />OTHER:$ <br />COMBINED SINGLE LIMIT <br />1,000,000 <br />A <br />AUTOMOBILE LIABILITY <br />$ <br />(Ea accident) <br />ANY AUTO 1-TTS-CA-19-01257312-006/1/20216/1/2022 <br />BODILY INJURY (Per person)$ <br />X <br />OWNEDSCHEDULED <br />X <br />AUTOS ONLYAUTOSBODILY INJURY (Per accident)$ <br />PROPERTY DAMAGE <br />HIREDNON-OWNED <br />XX <br />(Per accident)$ <br />AUTOS ONLYAUTOS ONLY <br />Unin Motor <br />X <br />$ <br />5,000,000 <br />B <br />XX <br />UMBRELLA LIABOCCUR <br />EACH OCCURRENCE$ <br />GBX200132-006/25/20216/1/2022 <br />5,000,000 <br />EXCESS LIABCLAIMS-MADE <br />AGGREGATE$ <br />0 <br />X <br />DEDRETENTION$ <br />$ <br />PEROTH- <br />WORKERS COMPENSATION <br />C <br />X <br />STATUTEER <br />AND EMPLOYERS' LIABILITY <br />Y / N <br />WVE 5020840 114/1/20224/1/2023 <br />1,000,000 <br />X <br />ANY PROPRIETOR/PARTNER/EXECUTIVE <br />E.L. EACH ACCIDENT$ <br />N / A <br />OFFICER/MEMBER EXCLUDED? <br />1,000,000 <br />(Mandatory in NH) <br />E.L. DISEASE - EA EMPLOYEE$ <br />If yes, describe under <br />1,000,000 <br />DESCRIPTION OF OPERATIONS belowE.L. DISEASE - POLICY LIMIT$ <br />GKLL1-TTS-CA-19-01257312-006/1/20216/1/2022 <br />Ded $500500,000 <br />A <br />On-Hook/Cargo1-TTS-CA-19-01257312-006/1/20216/1/2022 <br />Ded $1000150,000 <br />A <br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) <br />Job CITYO25 <br />City of Santa Ana, its officers, employees, agents and representatives are named as additional insured with respects to general and auto liability of the named <br />insured, pursuant to written contract, agreement or memorandum of understanding. Coverage is primary and non-contributory. General liability additional <br />insured endorsement CG2026(1219) and primary and non-contributory wording endorsement CG7680(1002) attached. Blanket auto liability additional insured <br />endorsement CA7110(0307) attached. Blanket workers compensation waiver of subrogation endorsement WC990634(0800) attached. *30 day notice of <br />cancellation applies/10 day notice for non-payment. <br />CERTIFICATE HOLDERCANCELLATION <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />City of Santa Ana Risk Management Division <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />20 Civic Center Plaza <br />Santa Ana, CA 92702 <br />AUTHORIZED REPRESENTATIVE <br />ACORD 25 (2016/03)© 1988-2015 ACORD CORPORATION. All rights reserved. <br />The ACORD name and logo are registered marks of ACORD <br /> <br />