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DATE(MM/DD/YYYY)
<br /> A�" CERTIFICATE OF LIABILITY INSURANCE
<br /> 08/06/2024
<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 CONTACT Nataly Hague CISR
<br /> NAME:
<br /> _James G.Parker Insurance_ PHONE
<br /> �Xt: (559)222-7722 FAX No: (559)222-1724
<br /> License#0554959 MAIL
<br /> DDRESf
<br /> P O Box 3947 INSURE (S)AFFO DING COVERA E
<br /> Angie Acevoe( NAIC#
<br /> Fresno s A: i ,� �itle i e i l o — 3
<br /> INSURED INSURER B: Infinity Select Insurance Co • 20260
<br /> Superior Hot Tapping Services Inc INSURER C: Scottsdale Insurance Company 41297
<br /> Superior Are Welding Inc INSURERD: State Compensation Ins Fund 35076.
<br /> 7923 Old Oak Court INSURER E: Evanston Insurance Company 35378
<br /> Riverside 92506 INSURER F:
<br /> COVERAGES CERTIFICATE NUMBER: 24-25 WC BA GL UMB 23- REVISION NUMBER:
<br /> THIS IS TO CERTIFYTHAT 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 TYPE OF INSURANCE ADDL UBR POLICY NUMBER MM/DD YYYYMPOLICY EFF O DD YYYY LIMITS
<br /> ICY EXP
<br /> LTR INSD WVD
<br /> X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
<br /> DAMAGE_7CLAIMS-MADE �OCCUR PREM SESOEa occu«Dence $ 100,000
<br /> MED EXP(Any one person) $ 5,000
<br /> A Y Y MPOO82001008411 07/31/2024 07/31/2025 PERSONAL&ADV INJURY $ 1,000,000
<br /> GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000
<br /> POLICY PRO ❑ 2,000,000
<br /> JECT LOC PRODUCTS-COMP/OPAGG $
<br /> OTHER: $
<br /> AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000
<br /> Ea accident
<br /> X ANYAUTO BODILY INJURY(Per person) $
<br /> B OWNED SCHEDULED 50001616301 01/06/2024 01/06/2025 BODILY INJURY(Per accident) $
<br /> AUTOS ONLY AUTOS
<br /> HIRED NON-OWNED PROPERTY DAMAGE $
<br /> AUTOS ONLY AUTOS ONLY Per accident
<br /> X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000
<br /> C EXCESSLIAB CLAIMS-MADE XLS1228052 07/31/2024 07/31/2025 AGGREGATE $ 2,000,000
<br /> DED I I RETENTION$ 1 $
<br /> WORKERS COMPENSATION X1
<br /> SPER TATUTE EORH
<br /> AND EMPLOYERS'LIABILITY Y/N 1,000,000
<br /> ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $
<br /> D OFFICER/MEMBER EXCLUDED? F NIA Y 9334957-2024 03/15/2024 03/15/2025
<br /> (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000
<br /> If yes,describe under 1,000,000
<br /> DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
<br /> Contractors Pollution w/Incidental Aggregate-Limit $2,000,000
<br /> E Professional Liability CPLMOL120711 12/21/2023 12/21/2024 Each Pollution Condition $2,000,000
<br /> Each Act-E&O $2,000,000
<br /> DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
<br /> RE:Project#2021-31,SR-55/Ritchey Street Water Improvements.James W Fowler Co(Contractor),City of Santa Ana(Owner),and Owner's Consultants
<br /> where required by written contract,are included as additional insured with waiver of subrogation and Primary Non-contributory wording respects to General
<br /> Liability per form CG2010 1185,CG2404 1093,CG2001 0413 attached.Waiver of subrogation applies to the Workers compensation per form 2572
<br /> attached.Notice of Cancellation applies to workers compensation as per form 2065,attached.Umbrella Policy follows form.
<br /> CERTIFICATE HOLDER CANCELLATION
<br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br /> THE EXPIRATION DATE THEREOF,NOTICE WILL RE DELIVERED IN
<br /> City of Santa Ana Risk Management Division ACCORDANCE WITH THE POLICY PRO)
<br /> 20 Civic Center Plaza Risk ManaganenfDMsibn
<br /> AUTHORIZED REPRESENTATIVE ' REVIEWED br APPROVED BY.
<br /> Santa Ana CA 92702 }pj ® Risk Management Specialist
<br /> ©1988-2015 ACOF
<br /> ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
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