|
A� 'a 71216/2024
<br /> MM/DD/YYYY)
<br /> CERTIFICATE OF LIABILITY INSURANCE
<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 6013466 1-562-270-0787 CONTACT NAME: Jose L. Gurrola
<br /> Bear Risk Management, Inc. PHONE 562-270-0787 FAX
<br /> (A/C.
<br /> /C No Ext: A/C No),
<br /> dba JL Gurrola Insurance Agency E-MAIL ia.comg certificatesnow@'1
<br /> ADDRESS: certificatesnow@jlgia.com
<br /> 100 W. Broadway Suite 3000 INSURER(S)AFFORDING COVERAGE NAIC#
<br /> Long Beach CA 90802 USA INSURERA: Scottsdale Insurance Company 41297
<br /> INSURED INSURERB: United Financial Casualty Company 11770
<br /> Dominguez General Engineering, Inc. Everest Premier Insurance Company 16045
<br /> INSURER C: P Y
<br /> dba Dominguez General Engineering Contractor INSURERD: Evanston Insurance Company 35378
<br /> 11096 Pipeline Ave.
<br /> INSURER E: Travelers Property Casualty 25674
<br /> Pomona CA 91766 USA INSURER F:
<br /> COVERAGES CERTIFICATE NUMBER: 1216-06-GA 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 IN SD WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY
<br /> X COMMERCIAL GENERAL LIABILITY X X BCS2002162 12/15/24 12/15/25
<br /> EACH OCCURRENCE $ 1,000,000
<br /> CLAIMS-MADE OCCUR DAMAGE TO RENTED
<br /> PREMISES Ea occurrence $ 300,000
<br /> A X Deductible: $ 5,000 MED EXP(Any one person) $ 5,000
<br /> PERSONAL&ADV INJURY $ 100,000
<br /> GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
<br /> PRO-
<br /> POLICY R1XIECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000
<br /> OTHER: $
<br /> NED
<br /> AUTOMOBILE LIABILITY X X 975624551 12/15/24 06/15/25 Ea accc" ",)SINGLE LIMIT $ 1,000,000
<br /> ANY AUTO BODILY INJURY(Per person) $
<br /> B X OWNED X SCHEDULED BODILY INJURY(Per accident)
<br /> AUTOS ONLY AUTOS $
<br /> HIRED NON-OWNED PROPERTY DAMAGE
<br /> AUTOS ONLY X AUTOS ONLY Per accident $
<br /> S
<br /> UMBRELLALIAB X OCCUR XLS2005843 12/15/24 12/15/25 EACH OCCURRENCE $ 4,000,000
<br /> A X EXCESS LIAB CLAIMS-MADE AGGREGATE $ 4,000,000
<br /> DED RETENTION$ N/A $
<br /> WORKERANDEMPSYERS'LIATIONILIT X 7600024851241 10/01/24 10/01/25 X STATUTE EER ER H
<br /> AND EMPLOYERS'LIABILITY Y/N
<br /> ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000
<br /> C OFFICER/MEMBEREXCLUDED? Y N I 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 /> D Contractors Pollution Lia. X X CPLMOL124441 06/10/24 06/10/25 Ea Occ & Agg Limit $ 2,000,000
<br /> E Property/Inaland Marine X X 660 3X218203 10/01/24 10/01/25 Installation Limit $ 700,000
<br /> E Property/Inaland Marine X X 660 3X218203 10/01/24 10/01/25 Lsd/Rntd Equipment $ 100,000
<br /> DESCRIPTION OF OPERATIONS 1 LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
<br /> Re: Project No. 21-6453 NE Annexation Water & Sewer Maint Improvements
<br /> The City of Santa Ana, its officers, officials, employees and volunteers are additional insured per attached endorsement(s).
<br /> Coverage is primary and non-contributory per policy wording and attached endorsement(s).
<br /> Waiver of Subrogation applies per attached endorsement(s).
<br /> Excess Liability is follow form.
<br /> APPROVED
<br /> By Tu Tran Nguyen at 12:01 pm,Jan 30,2025
<br /> 30 Day Notice of Cancellation/ 10 Day for Non-Payment.
<br /> CERTIFICATE HOLDER CANCELLATION
<br /> The City of Santa Ana
<br /> Risk Management Division 4th Floor 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 /> 20 Civic Center Plaza
<br /> AUTHORIZED REPRESENTATIVE
<br /> Santa Ana CA 92701 USA
<br /> ned
<br /> Tu Tran by Nquy Tran
<br /> en
<br /> ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Nguyen 2025 Date:
<br /> BEARRISK06 12 0
<br /> 2 iso
<br /> :zi-os as
<br /> 1216-06-GA
<br />
|