|
Francine R. Dyltaoy signed by Francine
<br />'. R.Vlllmeal
<br />Date: 2021.11.08 let 3:42
<br />ACORO® CERTIFICATE OF LIABILITY INSURANCE mwm
<br />yAT IDDIYY(Y)
<br />10/25/2021
<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 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(les) 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 Erica Hornaday
<br />The Empire Company
<br />PHONE FAX
<br />A/C No Exl: AIC Nob
<br />550 North Park Center Drive
<br />E-MAIL ADDRESS: ehornadayQempire-co.com
<br />Suite 205
<br />INSURERS) AFFORDING COVERAGE
<br />NAICq
<br />Santa Ana CA 92705
<br />INSURERA: Sentinel Insurance Company, LTD
<br />11000
<br />INSURED
<br />INSURERS: Trumbull Insurance Company
<br />27120
<br />RSG, Inc.
<br />INSURERC: Argonaut Insurance Company
<br />19801
<br />17872 Gillette Ave., Suite 360
<br />INSURER D :
<br />INSURER E:
<br />Wire CA 92614
<br />INSURER F:
<br />COVERAGES CERTIFICATE NUMBER: 21122 2nd Updt REVISION NUMBER:
<br />THIS ISTO CERTIFYTHATTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUEOTOTHE INSURED NAMEDABOVE FORTHE POLICY PERIOD
<br />INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT VVITH RESPECT TO WHICH THIS
<br />CERTIFICATE MAYBE 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 />SR
<br />LTR
<br />TYPE OF INSURANCE
<br />ADDILSUBR
<br />INSD
<br />WVD
<br />POLICYNUMBER
<br />POLICY EFF
<br />MMIDD=YV
<br />POLICY EXP
<br />MMIDD"YY
<br />LIMITS
<br />COMMERCIAL GENERAL LIABILITY
<br />CLAIMS -MADE OCCUR
<br />EACH OCCURRENCE
<br />$ 1,000,000
<br />DAMAGE TO RENT
<br />PREMISES E9 occurrence
<br />$ 1,000,000
<br />MED EXP (Any one person)
<br />$ 10,000
<br />PERSONAL &ADV INJURY
<br />$ 1,00D,000
<br />A
<br />72SBAAQ7019
<br />01/01/2021
<br />01/01/2D22
<br />G ENT AGGREGATE LIM IT APPLIES PER:
<br />X POLICY PRO-
<br />JECT ❑ LOC
<br />GENERALAGGREGATE
<br />$ 2,00D,000
<br />PRODUCTS-COMP/OPAGG
<br />$ 2,000,000
<br />$
<br />OTHER,
<br />AUTOMOBILE
<br />LIABILITY
<br />COMBINED SINGLE LIMIT
<br />Ea accident
<br />$ 1,000,000
<br />BODILY INJURY (Per person)
<br />$
<br />ANYAUTO
<br />A
<br />OWNED SCHEDULED
<br />AUTOS ONLY AUTOS
<br />HIRED NON -OWNED
<br />AUTOS ONLY X AUTOS ONLY
<br />72SBAAQ7019
<br />01/01/2021
<br />01/01/2022
<br />IX
<br />BODILY INJURY (Per axldent)
<br />$
<br />PROPERTY DAMAGE
<br />Peraccidenl
<br />$
<br />X
<br />UMBRELLA LIAB
<br />OCCUR
<br />EACH OCCURRENCE
<br />$ 2,000,000
<br />A
<br />EXCESS LIAB
<br />CLAIMS -MADE
<br />72SBAAQ7019
<br />01/0112021
<br />01/01/2022
<br />AGGREGATE
<br />$ 2,000,000
<br />❑EO
<br />X RETENTION $ 10,00D
<br />$
<br />B
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY YIN
<br />ANYETORIPARTNCUTIVE
<br />OFFICER)MEMBER EXCLUDED?
<br />(Mandildescribe
<br />NA
<br />72WECVK8727
<br />01/0112021
<br />01/0112022
<br />X PER OTH-
<br />/� STAT UTE ER
<br />E.LEACHACCmENT
<br />1,000,000
<br />$
<br />E.L. DISEASE -FA EMPLOYEE
<br />$ 1,000,000
<br />f yes, describe antler
<br />DESCRIPTION OF OPERATIONS below
<br />E.L. DISEASE - POLICY LIMIT
<br />$ 1,000,000
<br />Errors B Omissions
<br />LIMIT
<br />2,000,000
<br />C
<br />Claims Made
<br />121MPLD167514-01
<br />03f01l2021
<br />0310112022
<br />DEDUCTIBLE
<br />10,000
<br />DESCRIPTION OF OPERATIONSI LOCATIONS I VEHICLES (ACORD 1e1,Addilienal Remarks Schedule, may be attached Amore space is required)
<br />RE: RFQ No. 21-107 Affordable Housing Financial, Analytical And Advisory Services.
<br />City of Santa Ana, Its agents, officers, officials, employees, and volunteers are named as additional Insured on this policy pursuant to written contract,
<br />agreement, or memorandum of understanding. Such insurance as is afforded by this policy shall be primary, and any insurance carried by City shall be
<br />excess and non-contributory under the General Liability, where required by written contract, per form (SS 4171 1219) and (SS 00 08 04 05). Completed
<br />Operations additional insured applies per form (SS 4171 12 19). General Liability is Primary and Non -Contributory per form (SS 00 08 04 05). Auto liabliry
<br />additional insured per form SSO4380909 attached. General Liability and Worker's Compensation Waiver of Subrogation per forms (SS 00 08 04 05) and (WC
<br />04 03 06).
<br />City of Santa Ana Risk Management Division
<br />20 Civic Center Plaza
<br />Santa Ana
<br />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 PROVISIONS.
<br />/ If,
<br />©19B8-2016 ACORC
<br />ACORD 26 (2016103) The ACORD name and logo are registered marks of ACORD
<br />r.�a�e RIslaMarugelnnitDivlRllm
<br />a REVIEWED & APPROVED BY.'
<br />if
<br />y-V'
<br />�$$ir9���$$1
<br />rztslc Managemem Analyst
<br />
|