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Digitally signed by Tori Pierson
<br />Tori Pierson Date: 2021.111610:51:45
<br />-08,00,
<br />AC"RV
<br />il,. ,..- CERTIFICATE OF LIABILITY INSURANCE
<br />DATE (MM;ODIYYYY)
<br />F10/25/2021
<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 A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
<br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
<br />IMPORTANT: If they 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 />NAME:IT 1,ynet'te (1,y'nn) Eye
<br />VAX
<br />A/C No ut : 905-075-3531 AtC, No);
<br />PIA Select Insuiancc Solutions
<br />ADDRESS: Lynn.e:ycf" G,pitiseleCtxom
<br />I 100 1i'ldu$frlal Rd.,'/3
<br />INSURERS) AFFORDING COVERAGE
<br />NAIL #
<br />INSURER A: Amco insurance Company
<br />002014
<br />Scan Carlos CA 94070
<br />INSURED
<br />INSURER B : Employers Insurance C.iroup
<br />10346
<br />Data Ticket„ Inc.
<br />INSURER C : Continental Casualty Company
<br />20443
<br />DBA: Revenue. F",xperts
<br />INSURER D : Scottsdale Insurance Company
<br />41297
<br />2603 Main Street, Ste. 300
<br />INSURER E : Travelers Casualty and Surety Company of America
<br />31194
<br />INSURERF:
<br />Irvine, CA 92614-4200
<br />COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
<br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
<br />INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
<br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
<br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
<br />LTR
<br />TYPE OF INSURANCE
<br />INSD
<br />WVD
<br />POLICY NUMBER
<br />MM/DD/YYYY)
<br />(MM/DDtYYYY)
<br />LIMITS
<br />COMMERCIAL GENERAL LIABILITY
<br />EACH OCCURRENCE
<br />$ 2,000,000
<br />CLAIMS -MADE a OCCUR
<br />PREMISES (Ea Occurrence)
<br />$.._ 100,()00
<br />MED EXP (Any one person)
<br />$ 5,0(IO
<br />PERSONAL S ADV INJURY
<br />$ 2,000„000
<br />A
<br />Y
<br />Y
<br />ACp GL,CO 3079509589
<br />11/01/2021
<br />11/01/2022
<br />GEN"L AGGREGATE LIMIT APPLIES PER:
<br />GENERAL. AGGREGATE
<br />$ 4,000,000
<br />POLICY PRO
<br />JECT OLOC
<br />PRODUCTS - COMP/OP AGO
<br />$ 4,00,000
<br />OTHER:
<br />$
<br />AUTOMOBILE
<br />LIABILITY
<br />(Ea accident)
<br />$ 1 „000,00(.)
<br />BODILY INJURY (Per person)
<br />$
<br />ANY AUTO
<br />A
<br />OWNED AUTOS SCHEDULED
<br />AUTOS ONLY
<br />AC;I' GLCO 3079509589
<br />11/01/2021
<br />11/01/2022
<br />BODILY INJURY (Per accident)
<br />$
<br />HIRED NON -OWNED
<br />AUTOS ONLY AUTOS ONLY
<br />PER I Y DAMAGE$
<br />(Per accident
<br />$
<br />UMBRELLA LIAR
<br />OCCUR
<br />EACH OCCURRENCE
<br />$ 2,000,000
<br />EXCESS LIAR
<br />CLAIMS -MADE
<br />ACT CAA 3079509589
<br />11/01/2021
<br />11/01/2022
<br />AGGREGATE
<br />$ 2,000,000
<br />DED RETENTION $
<br />$
<br />13
<br />ORKERS COMPENSATION
<br />ND EMPLOYERS` LIABILITY
<br />ANY PROPRIETORSPARTNER/EXECUTIVE Y / N
<br />OFFICER/MEMBEREXCLUDED? �
<br />Mandatory In NH)
<br />f yes, describe under
<br />ESCRIPTION OF OPERATIONS beaow
<br />N/A
<br />Y
<br />EIG4581764-02
<br />11/01/2021
<br />11/01/2022
<br />STATUTE ER
<br />E.L. EACH ACCIDENT
<br />_
<br />$ 1,000,000
<br />E.L. DISEASE - EA EMPLOYEE
<br />------
<br />$ 1,0C)0,000
<br />E.L. DISEASE - POLICY LIMIT
<br />$ 1,000,000
<br />See atuiched Additional Remarks
<br />Schedule for additional policies
<br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required)
<br />City of Santa Ana, officers, agents, employees, and volunteers are flamed as additional insured on the General Liability policy pursuant to Written Contract', a gyeement, or
<br />memorandum of understanding.
<br />The General Liability policy includes a Waiver of Subrogation, Primary & Non -Contributory wording and 30 day notice of eancelhat'ion as required by Written contract (see
<br />attached').
<br />Workers Compensation includes a Waiver of Subrogation (sec attached).
<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 ACCORDANCE WITH THE POLICY PROVISIONS.
<br />Risk Wane emeant Iivision AUTHO REPRESENTATIVH
<br />20 Civic Center Plaza, 4tli Root Dmaturt
<br />APPRovED '
<br />Santa Ana CA t2702 �. � 761u P&M600
<br />1968-2015 ACORD CI Risk Man.gc,,—,tCicn-lAde
<br />ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
<br />
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