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A Digitally signed
<br />AC"R o® CERTIFICATE OF LIABILII MINKNCE by Angie A
<br />ev °MI00/1'YYY)
<br />07/14/2022
<br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFE 1yeptTa= V,.- :ti IS
<br />CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR WKA $[)E BtI S
<br />BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE'S`;UING INSURER(S), AUTHORIZED
<br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
<br />IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed.
<br />If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
<br />this certificate does not confer rights to the certificate holder in lieu of such endorsement($).
<br />PRODUCER
<br />OONT CT Tina Cowie
<br />NAME:
<br />Cornerstone Specialty Insurance Services, Inc.
<br />N..Nd Ext. (714) 731-7700 FAX Not; (714) 731-7750
<br />14252 Culver Drive, A299
<br />'MAIL tina wrnerstonespecial com
<br />AODRESa. @ ty'
<br />INSURERS AFFORDING COVERAGE
<br />NAIC N
<br />INSURERA: Travelers Indemnity Co of Conn
<br />25682
<br />Irvine - CA 92604
<br />INSURED
<br />INSURER B: Travelers Property Casualty Co
<br />25674
<br />INSURERC: Travelers Casualty& Surety Co of America
<br />31194
<br />JASON ADDISON SMITH CONSULTING SERVICES, INC.,
<br />INSURER D:
<br />DBA: JAB PACIFIC
<br />INSURER E:
<br />P.O. BOX 2002
<br />Upland CA 91786
<br />INSURER F:
<br />COVERAGES ' CERTIFICATE NUMBER: 21122 COVERAGES 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 OFINSURANGE
<br />INSD
<br />MD
<br />POLICY NUMBER
<br />POLICY EFF
<br />MMmD/YYYY
<br />P LOYEXP
<br />MMmD/YYYY
<br />LIMITS
<br />-
<br />MERCIAL GENERALLIABIUTY
<br />EACH OCCURRENCE
<br />$ 2,000,000
<br />CLAIMS -MADE ® OCCUR
<br />*XAODDITIONAL
<br />PREMISES Ea occurrence
<br />$ 1.000.000
<br />MED EXPAny one person)
<br />$ 5,000
<br />INSURED
<br />X
<br />BLNKTWVROFSUBRO
<br />PERSONAL &ADV INJURY
<br />$ 2.000,000
<br />A
<br />Y
<br />Y
<br />680-1 H359042
<br />08/08/2021
<br />08/98/2022
<br />GENt AGGREGATE LIMITAPPLIES PER:
<br />GENERALAGGREGATE
<br />$ 4,000,000
<br />-
<br />© PRO El
<br />PRODUCTS-COMP/OP AGG
<br />$ 4,000,000
<br />POLICY ECT LOG
<br />$
<br />OTHER:
<br />AUTOMOBILE
<br />LIABILITY
<br />COMBINED SINGLE LIMIT
<br />Ea acddent
<br />$ 1,000,000
<br />BODILY INJURY (Per person)
<br />$
<br />ANYAUTO
<br />A
<br />OWNED SCHEDULED
<br />BA-OS426316
<br />08/08/2021
<br />08/08/2022
<br />BODILY I NJURY(Per accident)
<br />$
<br />AUTOS ONLY AUTOS
<br />PROPERTY DAMAGE
<br />Peraccidenl
<br />$
<br />HIRED NON -OWNED
<br />q
<br />AUTOS ONLY AUTOS ONLY
<br />$
<br />I
<br />I
<br />UMBRELLALIAS
<br />OCCUR
<br />-
<br />EACH OCCURRENCE
<br />$ 5,000,000
<br />B
<br />EXCESS LIAR
<br />11
<br />CLAIM3-MAOE
<br />CUP-3429T370
<br />08/08/2021
<br />08/08/2022
<br />AGGREGATE
<br />IS 5,000,000
<br />DEO
<br />I I RETENTION $
<br />$
<br />WORKERS COMPENSATION
<br />PER FROTH
<br />X
<br />EMPLOYERS' LIABILITY YIN
<br />STATUTE ER
<br />E.L. EACH ACCIDENT
<br />$ 1,000,000
<br />B
<br />ANY RlEXCLUDEEXECUTIVE 19
<br />NIA
<br />Y
<br />UB-BK37343A
<br />08/08/2021
<br />08/08/2022
<br />O EXCLUDED?
<br />OFFICE MEMB
<br />-
<br />E.L. DISEASE - EA EMPLOYEE
<br />$ 1,000,000
<br />(Mandatory In NH)
<br />Mandatory I. NH)
<br />Ifyes,descnbeunder
<br />1,000,000
<br />DESCRIPTION OF OPERATIONS be.
<br />E.L. DISEASE -POLICY LIMIT
<br />$
<br />Each Claim
<br />$2,000,000
<br />Professional Liability
<br />C
<br />Claims Made
<br />107296206
<br />08/08/2021
<br />08/08/2022
<br />Annual Aggregate
<br />99ate
<br />9
<br />$2,000,000
<br />DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required)
<br />City of Santa Ana, its officers, officials, employees, and volunteers are Additional Insured for General Liability but only if required by written contract with the
<br />Named Insured prior to an occurrence and as per attached endorsement. Coverage is subject to all policy terms and conditions. *30 days notice of
<br />cancellation, except for 10 days notice for non-payment of premium. For Professional Liability coverage, the aggregate limit is the total insurance available
<br />for all covered claims reported within the policy period.
<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
<br />Santa Ana CA 92702 V�RAManagemmtDMallnt by
<br />REVIEWED fi APPROVED BY:
<br />©1988-2015 ACOF 9� �' o. A+fla AaV44
<br />ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
<br />Risk Management SpeaaBt
<br />
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