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Francine Digitally Signed by <br />Francine R. VillereelPage 1 of 2 <br />Date: 202Li <br />ACO)!s',P� CERTIFICATE OF LIABILITY INSURANCE rea 08:30:55-0T 0' DAT9 2IY21 <br />29 <br />09/29/2021 <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 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 endorsement(s). <br />PRODUCER <br />CONTACT Willis Towers Watson Certificate Center <br />NAME: .—,- <br />Willis Towers Watson Insurance Services West, Inc. <br />PHONE FAQ—'-' <br />c/o 26 Century Blvd <br />-IAA 1. 1-877-945-7378�i IAIC NoJ: 1"888-167-2378 <br />P.O. Box 305191 <br />E•MAII certiflcate4willis,com <br />OD ESS: _ <br />Nashville, TN 372305191 USA <br />_ <br />INSURERLLAFFORDING COVERAGE <br />NAIC N <br />_ <br />IN5URERA; Westchester Surplus Lines Insurance Compan <br />10172 <br />INSURED <br />The salvation Army - Division 17 <br />INSURERB; Greenwich Insurance Company <br />22322 <br />INSURERC: XL Specialty Insurance Company <br />37885 — <br />30840 Hawthorne Blvd., Bldg D <br />Rancho Palo. Verdes, CA 90275 <br />INSURERD: <br />_ <br />_ <br />INSURER E: ._--- <br />- <br />INSURER F; <br />- <br />COVERAGES CERTIFICATE NUMBER- W22306682 0=1110VFJ Au mnnve,. <br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY <br />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 DL SUBR -----� POLICY EFF POLI'YEXP -'-- <br />TR TYPEOFINSURANCE D o POLICYNUMBER IDDIYYYY) (MMiDD?YYYYl LIMITS <br />X <br />COMMERCIALGENERAL LIABILITY <br />EACHOCCURRENCE <br />$ 21000,000 <br />_ <br />8 1,000,000 <br />JCLAIMS-MADE OOCCUR <br />-GAM�TSREffiE�- <br />PREMIS'S Ea occ rrancei_- <br />X <br />MED EXP. Any onopersen) <br />,__ <br />$ i0 <br />A <br />Self Insured Retention: <br />X <br />$1,000,000 <br />Y <br />G7183119A 002 <br />10/01/2021 <br />10/01/2022 <br />_PERSONAL &AOVINJURY <br />5 2,000, 000 <br />GENT. <br />e <br />AGGREGATE LIMITAPPLIES PER: <br />POLICY�X-11LOC <br />GENERAL AGGREGATE <br />$ 4,000,000 <br />Ir <br />PRODUCTS -COMPIOP AGG <br />$ 4,000,000 <br />$ <br />OTHER: <br />AUTOMOBILEUABILITY <br />CO BI. INGLE LIMI <br />$ <br />- <br />(Ea acclden0 <br />ANY AUTO <br />BODILY INJURY (Per person) <br />$ <br />OWNED SCHEDULED <br />BODILY INJURY (Par accident) <br />-.-- <br />$ <br />AUTOS ONLY AUT05 <br />HIRED NON -OWNED <br />AUTOS ONLY AUTOS ONLY <br />ROPEkhart) AGG <br />1Per acdtl¢ntl <br />------ <br />$ <br />UMBRELLA LIAB <br />OCCUR <br />EACH OCCURRENCE <br />$ <br />AGGREGATE <br />S <br />Excess LIAR <br />CWMS.MAOF. <br />DEDT1 <br />RETENTION$ <br />_ <br />$ <br />WORKERS COMPENSATION <br />AND EMPLOYERS'LIABILITY <br />STATUTE ER <br />YIN <br />EAC .L. EACHCIDENT <br />---- <br />$ <br />AhIYPROPRIETORIPARTNERIEXECUTIVE ❑ <br />OFFICERIMEMBEREXCLUDED? <br />NIA <br />E.I.DISEASE-CA EMPLOYEE <br />-- <br />$ <br />(Mandatory lnNH) <br />If yea, doecdbe under <br />E.L.DISEASE-POLICY LIMIT <br />$ <br />DESCRIPTION OF OPERATIONS below <br />a <br />Maness Auto Liability - CA <br />Y <br />RAM500021811 <br />10/01/2021 <br />10/01/2022 <br />Any Auto / CSL <br />$3,000,000 <br />I <br />I <br />Self-Insd Retention <br />$2,000,000 <br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached If more space is required) <br />Location Code: 17-145-10-01-01 - Santa Ana Hospitality House Shelter <br />CA -Business Auto is fully Self -Insured per the attached State Certificate. <br />SEE ATTACHED <br />City of Santa Ana <br />Risk Management Division <br />20 Civic Center Plaza <br />Santa Ana, CA 92702 <br />ACORD 25 (2016/03) <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />AUTHORIZED REPRESENTATIVE <br />The ACORD name and logo are registered marks of ACORD <br />as tu: 21630631 aA'TCH: 2252947 <br />Wait MAsm621hed1XVIefon <br />����i RBV1EViE.3 & FIMPaR',OpV�ED liY: <br />8�•181f.W9':l:) d6YtY%d� P, YmLSf ,4t <br />�' Risk Management Analyst <br />