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'qc_ "N" CERTIFICATE OF LIABILITY INSURANCE
<br />t,,,,
<br />DATE,MMIQDYYVY,
<br />112/2024
<br />THIS CERTIFICATE IS ISSUED A3 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 ilea of a endorsement(*),
<br />PRODUCER
<br />UNIAUI
<br />NAME: Lyttette (Lynn) eyc
<br />PIA Select Insurance Solutions - Service Location
<br />1938 Vista DO Oro
<br />A/C No EM : 805-975--3531 � (Arc No N/A
<br />"- "
<br />AoOa@s8: 1ynn.eye(gPi uselect.cooteam
<br />_`__ INSURER(S) AFFORDING COVERAGE
<br />NAICa
<br />Salto Muria CA 93458_
<br />INSURER A Colony Insurance Company
<br />39993
<br />__
<br />INSURED
<br />INSURERS: Employers Assurance Co.
<br />25402
<br />Onna Ticket Inc.
<br />INSURER C I Conrtinelnal Casualty Company
<br />20443
<br />DBA: Revenue Expartrc
<br />INSURER D: Arch Specialty insurance Cn_mpalry & see attached
<br />21199
<br />2603 Mahn Smwt, Sta. 300
<br />INSURER E: Travelers Casualty and Surety Company of America
<br />31194
<br />Irvine CA 926144200
<br />INSURER F:T —
<br />COVERAGES CERTIFICATE
<br />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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH rills
<br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN I$ SUBJECT TO ALL T14E TERMS,
<br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED SY PAID CLAIMS,
<br />_'
<br />TRW
<br />LTR
<br />_
<br />,-. TYPE OFINSURANGE
<br />IN30
<br />WVU
<br />POLICY NUMBER
<br />_..,......._.._
<br />MU�NEYYY�
<br />(MMfDb/YYVY
<br />UMI73
<br />COMMERCIAL GENERAL LIABILITY
<br />JCLAIMS-MADE ®OCCUR
<br />EACH OCCURRENCE
<br />e
<br />$ 1,000,000
<br />PREMISES Eaocmmenw
<br />100,000
<br />MED EXP(Any one person)
<br />$ 5,000
<br />_.....,.
<br />PERSONAL A ADV INJURY
<br />$ 1,000,000
<br />A
<br />Y
<br />Y
<br />103 OIL 0215056-01
<br />I1101/2024
<br />11/01/2025
<br />GEN'L AGGREGATE LIMIT APPLIES PER:
<br />ya POLICY ❑JEC []LOC
<br />GENERAL AGGREGATE
<br />S 2,000,000
<br />PRODUCTS - COMP/OP AGG
<br />$ 2,000,000
<br />$
<br />OTHER:
<br />AUTOMOBILE
<br />_
<br />LIABILITY
<br />DPRINE0:SIRGLE7.IM
<br />Ea accident)
<br />—
<br />$ 1,0001000
<br />ANY AUTO
<br />BODILY INJURY (Per person)
<br />$
<br />A
<br />XHIRED
<br />AUTOSONLY AU7Q8ULF.n
<br />NON -OWNED
<br />AUTOS ONLY AUTOS ONLY
<br />I(13 CiL 0215036d11
<br />II/01/2024
<br />11/0I1202$
<br />BODILY INJURY For ecGdgnl)
<br />S
<br />PROPER17TEMI$
<br />Perawltlenq
<br />w�
<br />UMBRELLA LIAR
<br />OCCUR
<br />�—
<br />EACH OCCURRENCE
<br />$ — 3,000,00O
<br />A
<br />X
<br />EXCESS LIAR
<br />CLAIMS -MADE
<br />XSI76835
<br />11/01/2024
<br />11/01/2025
<br />AGGREGATE _
<br />$ T 0�3,000,000
<br />DEU
<br />RETENTION
<br />$
<br />N
<br />_
<br />ORKERS COM ENS
<br />O EMPLOYERS' LIABILITY YIN
<br />ANY PROPRIETOIVPARTNERIEXECUTIVE �
<br />FFICERIMEMBER EXCLUDED? G 1
<br />(mandatory lnNH)
<br />Itmyillescnbe under
<br />ESGRIPTIONOFOPERATIONSaakrw
<br />NIA
<br />Y
<br />FIG4581764.05
<br />11/01/2024
<br />11/010025
<br />y
<br />I� STATUTE ER
<br />E.L.EACH ACCIDENT
<br />_
<br />$ ^-1,000_000
<br />-
<br />E.L. DISEASE - EA EMPLOYEE
<br />-
<br />-- -
<br />$ 1,000,000
<br />E.L. DISEASE, POLICY LIMIT
<br />-----
<br />$ 1,000,000.
<br />Sec attached Additional Remarks
<br />Schedule for additional policies
<br />DESCRIPTION OF OPERATIONS ILOCATIONS lVBIIICLES (ACORD 101, Additional Remarks Schedule, may be aUached It more epeae Is required)
<br />City of Santa Ann, its officers, officials, employees, and volunteers are named as additional insured on the General Liability policy pursuant Ie Written contract, Rip contain, at
<br />momorndum of understanding.
<br />The Geaerul liability policy includes It Waiver of Subrogluioll, Primary & Nondbnutibutony Wording mud 30 day notice orencellation as required by written contract (see
<br />attached). �---
<br />APPROVEB
<br />Wnrkere Commen[alinn 41flUdCR n Waiver of Soln aline Lees.nllanhndl.
<br />By Cynthia MDra at 8:57.am, Nov 13,.2024.
<br />PPPTRcIPATG N/1111GR PAMPFr I ATinM
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />City al'Sarn Ana
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />Risk Management Division
<br />AUTHORIZED REPRESENTATIVE
<br />20 Civic Center Plaza, 4th Flour
<br />Saran Ana CA 02702
<br />b 1988.2015 ACORD CORPORATION, Ali rights reserved.
<br />ACORD 25 (2016/03) The ACORD nama and logo are registered marks of ACORD
<br />
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