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Samantha Digitally signed by
<br />Samantha M. Lambert EMBROKER
<br />CERTIFICATE OF LIABILITY
<br />D0411`1/20022
<br />IM$1 I 30 09:16.40i0700'4
<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
<br />NAME:
<br />Embroker Insurance Services LLC
<br />PHONE FAC
<br />24 Shotwell Street
<br />8444362765 No:
<br />E-NAIL
<br />ADDRESS: certificates embroker.com
<br />San Francisco, CA, 94103
<br />INSURERS AFFORDING COVERAGE
<br />NAIC If
<br />INSURER A: Continental Casualty Company
<br />20443
<br />INSURED
<br />INSURER 8: Hartford Accident and Indemnity Company
<br />22357
<br />INSURER C: CLEAR BLUE INS CO
<br />28860
<br />Fifth Asset, Inc.
<br />300 W Summit Ave
<br />INSURER D: VALLEY FORGE INS CO
<br />20508
<br />STE 110
<br />Charlotte, NC, 28203
<br />INSURER E:
<br />INSURER F :
<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 />INSR
<br />LTR
<br />TYPE OF INSURANCE
<br />ADDL
<br />SUER
<br />POLICY NUMBER
<br />MM%DPOLICYIYEYFYFY
<br />POLICY EXP
<br />MMnXVYYYY
<br />LIMITS
<br />MMERCIAL GENERAL LIABILITY
<br />❑X OCCUR
<br />T
<br />EACH OCCURRENCE
<br />$ 1,000,000
<br />RENTED
<br />DAMAGCLAIMS-MADE
<br />PREMISES
<br />PREMISES Ea occurrence
<br />81,000,000
<br />MED UP (Any one person)
<br />$ 10,000
<br />D
<br />Y
<br />Y
<br />7012519506
<br />11/01/2021
<br />11/01/2022
<br />PERSONAL BAOV INJURY
<br />$ 1,000,000
<br />GEN'L AGGREGATE LIMIT APPLIES PER
<br />GENERAL AGGREGATE
<br />$ 2,000,000
<br />X POLICY PRO-
<br />JECT LOC
<br />PRODUCTS-COMPIOPAGG
<br />$ 2.000,000
<br />$
<br />OTHER:
<br />AUTOMOBILE
<br />LIABILITY
<br />COMBINED SINGLE LIMIT
<br />Ea amdent
<br />$ 1,000,000
<br />BODILY INJURY (Per person)
<br />$
<br />ANY AUTO
<br />D
<br />OWNED
<br />AUTOS ONLY AUTOSULED
<br />Y
<br />Y
<br />7012519506
<br />11/01/2021
<br />11/01/2022
<br />BODILY INJURY (Per accidan0
<br />$
<br />X
<br />HIRED X NON -OWNED
<br />AUTOS ONLY AUTOS ONLY
<br />PROPERTY DAMAGE
<br />Per accitlent
<br />$
<br />X
<br />UMBRELLA LIAR
<br />X
<br />OCCUR
<br />EACH OCCURRENCE
<br />$ 2,000,000
<br />AGGREGATE
<br />$ 2,000,000
<br />A
<br />EXCESS UPS
<br />CLAI:MADE
<br />7015209125
<br />11/01/2021
<br />11/01/2022
<br />DED I X I RETENTION$ 10,000
<br />$
<br />B
<br />WORKERS COMPENSATION
<br />EMPLOYERS' LIABILITY YIN
<br />ANYPROPRIETORIPARTNEREX
<br />REXCWO py ECUTIVE �
<br />OFFICER(Mandatory in NH)
<br />NIA
<br />57WECAPOTHP
<br />12/13/2021
<br />11/01/2022
<br />PER OR
<br />X STATUTE ER
<br />E.L. EACH ACCIDENT
<br />$ 1,000,000
<br />E.L. DISEASE - EA EMPLOYEE
<br />$ 1,000,000
<br />If yes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />I
<br />E.L. DISEASE -POLICY LIMIT
<br />$ 1.000,000
<br />C
<br />Commercial Crime
<br />CR01-100199-211
<br />12/20/2021
<br />12/20/2022
<br />Aggregate
<br />1,000,000
<br />C
<br />Technology Errors And Omissions Cyber
<br />AX01-1037-03
<br />02/01/2022
<br />02/01/2023
<br />Aggregate
<br />5,000,000
<br />C
<br />I Employment Practices Liability
<br />AX01-1037-03
<br />02/01/2022
<br />02/01/2023
<br />Aggregate
<br />1,000,000
<br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
<br />CLEAR BLUE INS CO, NAIC#28860
<br />Indemnifiable Directors and Officers Liability - AXO 1 -1037-03, 02/01/2022 - 02/01/2023 Aggregate $1,000,000
<br />City of Santa Ana, CA, its officers, officials, employees, and volunteers is listed as an Additional Insured on the General Liability and Auto Liability policies
<br />as per written contract.
<br />A Waiver of Subrogation applies to City of Santa Ana, CA, its officers, officials, employees, and volunteers with respect to the General Liability and Auto
<br />Liability policies as per written contract.
<br />City of Santa Ana
<br />Risk Management Division
<br />20 Civic Center Plaza, 4th Floor
<br />Santa Ana, CA 92701
<br />SHOULD ANY OF THE ABOVE DESCRIBI
<br />THE EXPIRATION DATE THEREOF,
<br />ACCORDANCE WITH THE POLICY PROV
<br />AUTHORIZED REPRESENTATIVE
<br />©1988.2015 ACORD
<br />a ,a,..,� R4kMwyvnedl%vlrlon
<br />t"°: REVIEWED&APPRrO�VED, B�Yr:
<br />8I W... SRMvcaL{lQA l
<br />i�. Risk Management Supervhw
<br />reserved.
<br />ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
<br />
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