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Digita l ly signed by Torl Pierson
<br />Tori Pierson �ate:2022.05.1815:53:41
<br />,z9,00RDI CERTIFICATE of LIABILITY INSURANCE
<br />-DATE(MMMDmvY)
<br />`4._ " -
<br />5/1712022
<br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CHOLDER. THIS
<br />ERTIFICATE
<br />CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED TE 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(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 endorsements .
<br />PRODUCER Phone: (707 996.2912
<br />Fox; (707 &7912
<br />Apollo General Insurance Agency, Ins. (I)Exit
<br />P. O. Box 1508
<br />Sonoma, California 95476
<br />coNEA T 7erilee Carpenter
<br />PHONE FAX o
<br />e.MAleae: jerileec®apgon.com
<br />INSURER S AFFOROING COVERAGE
<br />NAICN
<br />INSURERA: TokloMarine Specialty lnsuranceCompany
<br />23850
<br />INSURED
<br />INSURER D: State Cora ensalion Insmunce Fund Of California
<br />35076
<br />J&G Industries, Inc.
<br />18627 Brockhurst Street
<br />PMB 302
<br />INSURER C I Westchester Surplus Linea Insurance Company
<br />16172
<br />INSURER or
<br />INSURER E:
<br />Fountain Valley, CA 92708
<br />INSURER F:
<br />COVERAGES CERTIFICATF NI IMRFR-1202 eso nc.,
<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
<br />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 />N
<br />ILTR
<br />TYPE OF INSURANCE
<br />ADDI
<br />SUBF
<br />OLICY NU BE
<br />POLIICYEFF
<br />II/l/2021
<br />PMlDO
<br />II/l/2022
<br />LIMITS
<br />A
<br />✓
<br />COMMERCIAL GENERAL LIABILITY
<br />CLAIMS OCCUR
<br />PPK2344578
<br />EACHOCCURRENCE
<br />$ 1,000,000
<br />RE T
<br />-MADE
<br />e
<br />$ 00,00
<br />MEDFXP An one rarm
<br />$
<br />✓
<br />Y
<br />PERSONAL&ADVINJURY
<br />3 1,000,000
<br />LIMITAPPLIES PER:
<br />POUCY ✓❑ PEQ
<br />GENEMLAGGREGATE
<br />$ 2,000,000
<br />GENLAGGREGATE
<br />PRODUCTS-COMP/OP AGO
<br />$ 2,000,000
<br />too
<br />$
<br />OTHER:
<br />AUTOMOalLELIABILITY
<br />COMBINEDSINGLE L
<br />e ldera
<br />$
<br />ANY AUTO
<br />BODILY INJURY (Par Person)
<br />$
<br />OWNED SCHEDULED
<br />AUTOS ONLY pU�os
<br />eOOILY INJURY (Per emldant)
<br />$
<br />MCA ONLY AUTO ONLY
<br />ecel e I
<br />erED awl oil
<br />$
<br />A
<br />UMSRELLAUAB
<br />✓
<br />OCCUR
<br />PUB791516
<br />11/1/2021
<br />11/1/2022
<br />EACHOCCURRENCE
<br />$ $,000,000
<br />✓
<br />EXCESS LIAB
<br />CLAIMS -MADE
<br />nccREcnrE
<br />$ 5,000,000
<br />BED I I RETENTION
<br />$
<br />✓
<br />Y
<br />B
<br />WORKERS COMPENSATION Y/N
<br />AND EMPLOYERS' LIABILITY
<br />0802847-202I
<br />10/1/2021
<br />10/1/2022
<br />✓ STgT SIT
<br />E,L. EACH ACCIDENT
<br />$ 1,000,000
<br />ANYPROPRIETOWPARTNEMEXECUTIVE
<br />OFFICERIMEMBEREXCLUDED?
<br />NIA
<br />Y
<br />E.L. DISEASE-FAEMPLOYEE
<br />$ 1,000,000
<br />IMendd se in NHl
<br />fffyyes desedbe under
<br />E.L. DISEASEPOLICYLIMIT
<br />$ 1,000,000
<br />OE3GI PnON OF OPERATIONS bela
<br />C
<br />Pollution Liability
<br />✓
<br />Y
<br />G7359319Ao01
<br />11/1/2021
<br />11/1/2022
<br />Sees Coaaiaos:
<br />5,000,000
<br />Cxnasl Aru ,a
<br />5,000,00
<br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Addlllonal Remarks Sohedulo, maybe attached it more spaoo is required)
<br />Re: Operations of the Named Insured. City of Santa Ana is hereby named as Additional Insured, if required by written
<br />contract, per endorsement hereto. Waiver of Subrogation is provided, as required by written contract with the insured
<br />as respects coverage evidenced herein. Coverage evidenced herein is primary and non-contributory. Excess is follow
<br />form to the underlying General Liability, Commercial Auto and Workers Compensation Coverage listed. A 30-day written
<br />notice shall be mailed to the Certificate holder at the address provided herein, should a described policy(s) be
<br />cancelled before the expiration date thereof] ID -Clay notice for non-payment of premium.
<br />Holder's Nature of Interest: Additional Insured
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />City Of Banta Ana THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />Risk Management Division
<br />20 Civic Center Plaza AUTHORIZEDSEPy6SENTATIVE
<br />Santa Ana, CA 92701
<br />©1888-2016ACOR OI ,ia4d
<br />ACORD 26 (2016103) The ACORD name and logo are registered marks of ACORD
<br />Riskhtnaaem'»CCimelAida
<br />
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