|
DATE(MM/DD/YYYY)
<br /> A�" CERTIFICATE OF LIABILITY INSURANCE 6/24/2025
<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
<br /> NAME: Patty Carreon
<br /> Arthur J. Gallagher Risk Management Services, LLC PHONE FAX
<br /> 18201 Von Karman Ave A/C No Ext: 760-482-2799 A/C,No):
<br /> E-MSuite 200 ADDRESS: Patty_Carreon@ajg.com
<br /> Irvine CA 92612 INSURER(S)AFFORDING COVERAGE NAIC#
<br /> License#:OD69293 INSURERA: Hartford Underwriters Insurance Company 30104
<br /> INSURED INSURERB: Employers Preferred Insurance Company 10346
<br /> Carpenter, Rothans &Dumont
<br /> 500 S Grand Ave, Suite 1900 INSURERC:
<br /> 19th Floor INSURERD:
<br /> Los Angeles CA 90017 INSURERE:
<br /> INSURER F:
<br /> COVERAGES CERTIFICATE NUMBER:888136359 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS
<br /> LTR INSD WVD POLICYNUMBER MM/DD MM/DD
<br /> A X COMMERCIAL GENERAL LIABILITY Y 83SBABH9S5X 2/11/2025 2/11/2026 EACH OCCURRENCE $1,000,000
<br /> DAMAGES( RENTED
<br /> CLAIMS-MADE OCCUR
<br /> PREMISES Ea occurrence)
<br /> ccurrence) $1,000,000
<br /> MED EXP(Any one person) $10,000
<br /> PERSONAL&ADV INJURY $1,000,000
<br /> GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000
<br /> POLICY❑ PRO ❑
<br /> JECT LOC PRODUCTS-COMP/OP AGG $2,000,000
<br /> X
<br /> OTHER: Deductible $2,500
<br /> A AUTOMOBILE LIABILITY 83SBABH9S5X 2/11/2025 2/11/2026 COMBINED SINGLE LIMIT $1,000,000
<br /> Ea accident
<br /> ANY AUTO BODILY INJURY(Per person) $
<br /> OWNED SCHEDULED BODILY INJURY(Per accident) $
<br /> AUTOS ONLY AUTOS
<br /> X HIRED X NON-OWNED PROPERTY DAMAGE $
<br /> AUTOS ONLY AUTOS ONLY Per accident
<br /> A X UMBRELLA LAB X OCCUR 83SBABH9S5X 2/11/2025 2/11/2026 EACH OCCURRENCE $4,000,000
<br /> EXCESS LAB CLAIMS-MADE AGGREGATE $4,000,000
<br /> DED X RETENTION$1 n nnn $
<br /> B WORKERS COMPENSATION Y EIG595181600 5/9/2025 5/9/2026 X PER OTH-
<br /> AND EMPLOYERS'LIABILITY Y/N STATUTE ER
<br /> ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000
<br /> OFFICER/MEMBER EXCLUDED? ❑ N/A
<br /> (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000
<br /> If yes,describe under
<br /> DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000
<br /> DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required)
<br /> The City of Santa Ana, its officers,officials,employees,and volunteers included as an Additional Insured(s)as respects to General Liability policy,pursuant to
<br /> and subject to the policy's terms,definitions,conditions and exclusions.'Except 10 days notice of cancellation for non payment of premium.Waiver of
<br /> Subrogation applies to Additional Insured(s)as respects to Workers Compensation policy, pursuant to and subject to the policy's terms,definitions,conditions
<br /> and exclusions.
<br /> DigiaTu Tran TuTca yNsigned by
<br /> °2 057-070 Nguyen APPROVED
<br /> �By Tu Tran Nguyen at 2:20 pm,Jun 27,2025
<br /> CERTIFICATE HOLDER CANCELLATION
<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 /> Attention: City Attorney's Office
<br /> 20 Civic Center Plaza AUTHORIZED REPRESENTATIVE
<br /> Santa Ana CA 92702 -�
<br /> USA
<br /> @ 1988-2015 ACORD CORPORATION. All rights reserved.
<br /> ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD
<br />
|