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17 IQI ILII IC r%' Francine R. Villareal <br />ACORO® CERTIFICATE OF LIABILITY INSURANCE Villare <br />`,� <br />DhTE fy.II <br />01/14/2022 <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 Customer Service Department <br />NAME <br />Gaslamp Insurance Services <br />2244 Faraday Avenue, #125 <br />PHONE (760) 429-2953 FAx (800) 920-4107 <br />Ezt: ANo <br />E-MAIL <br />ADDRESS: <br />INSURERIS) AFFORDING COVERAGE <br />NAIL # <br />INSURER A: Clear Blue Specialty Ins Co <br />37745 <br />Carlsbad CA 92008 <br />INSURED <br />INSURER B: Nautilus Insurance Company <br />17370 <br />Superior Hot Tapping Services, Inc. <br />INSURER C : Evanston Insurance Co <br />35378 <br />PO Box 1317 <br />INSURER D <br />INSURER E <br />Bloomington CA 92316 <br />1 INSURER F: <br />COVERAGES CERTIFICATE NUMBER: GL PP 21-22 XS 22-23 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 CONTRACTOR OTHER DOCUMENT WITH 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 />INSR <br />LTR <br />TYPE OF INSURANCE <br />ADDIL <br />INSID <br />Sum <br />WVD <br />POLICY NUMBER <br />POLICY EFF <br />MM/3D/YY1YI <br />POLICY EXP <br />(MMIDDADI <br />LIMITS <br />X <br />COMMERCIAL GENERAL LIABILITY <br />CLAIMS -MADE ® OCCUR <br />EACH OCCURRENCE <br />$ 1,000,000 <br />DAMAGE TO RE ED <br />PREMISES Ea occurrence <br />100,000 <br />$ <br />MED EXP (Any one person) <br />$ 5,000 <br />PERSONAL B ADV INJURY <br />$ 1,000.000 <br />A <br />Y <br />Y <br />AR01-RS-2103167-00 <br />08/20/2021 <br />OB/20/2022 <br />GEN'LAGGREGATE LIMIT APPLIES PER: <br />PRO- <br />POLICY PRO <br />JECT LED <br />GENERALAGGREGATE <br />$ 2,000,000 <br />PRODUCTS-COMP/OP AGG <br />$ 2,000,000 <br />$ <br />OTHER: <br />AUTOMOBILE <br />LIABILITY <br />COMBINED SINGLE LIMIT <br />Ea accident <br />$ <br />BODILY INJURY (Per person) <br />$ <br />ANYAUTO <br />OWNED SCHEDULED <br />AUTOS ONLY AUTOS <br />BODILY INJURY (Per acrJdenU <br />$ <br />HIRED NONoWNED <br />AUTOS ONLY AUTOS ONLY <br />PROPERTY DAMAGE <br />Peraccidenl <br />$ <br />UMBRELLA LIAR <br />OCCUR <br />EACH OCCURRENCE <br />$ 2,000,000 <br />11 <br />AGGREGATE <br />$ 2,000,000 <br />B <br />EXCESS LIAB <br />CLAIMS -MADE <br />Y <br />Y <br />AN1253544 <br />01/14/2022 <br />08/20/2022 <br />DED <br />I I RETENTION $ <br />$ <br />WORKERS COMPENSATION <br />AND EMPLOYERS' LIABILITY YIN <br />I PER OTH- <br />STATLITE ER <br />E.L. EACH ACCIDENT <br />$ <br />ANY PROPRIETOR/PARTNERIEXECUTIVE <br />OFPICERIMEMBER EXCLUDED? <br />NIA <br />E.L DISEASE - EA EMPLOYEE <br />$ <br />(Mandatory In NH) <br />If yes, describe under <br />E.L. DISEASE -POLICY LIMIT <br />$ <br />DESCRIPTION OF OPERATIONS below <br />C <br />Contractors Pollution Liability <br />Errors and Omissions <br />CPLMOL109303 <br />12/21/2021 <br />12121/2022 <br />Each Occurrence <br />Aggregate <br />2,000,000 <br />2,000,000 <br />Each Occurrence <br />2,000,000 <br />DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached R more space is required) <br />The City of Santa Ana, its officers, officials, employees, and volunteers are named as Additional Insured for Ongoing and Completed Operations; Primary <br />Non -Contributory Wording, Waiver of Subrogation applies, to the extent provided in the attached form(s). Excess follows forth. <br />*Additional Insured status is subject to all policy terms, exclusions and conditions* <br />HOLDER <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 ACCORDANCE WITH THE POLICY PROVISIONS. <br />20 Civic Center Plaza <br />AUTHORIZED REPRESENTATIVE �J <br />Santa Ana CA 97202 //�(j_ ee^+< 1Z1eItMroM�mentDivisian <br />�_'REVIEwEn 6 APPRov®Br. <br />©1988-2015 ACOR <br />ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD glEc7lium' <br />Risk Management Analyst <br />