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�"1 MIKEBUB-01 ASHUNN
<br /> AC-CPRO CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)
<br /> 2/5/2025
<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 License#0M63276 CONTACT
<br /> NAME:
<br /> Gallant Risk and Insurance Services,LLC PHONE FAX No 368-0707
<br /> 4160 Temescal Canyon Rd.Suite 214 (ANC,No,Ext):(951)368-0700 I ( ):(951)
<br /> Corona,CA 92883 ADDRESS:
<br /> INSURER(S)AFFORDING COVERAGE NAIL#
<br /> INSURER A:Hartford Fire Insurance Company 19682
<br /> INSURED INSURER a:Trumbull Insurance Company 27120
<br /> Mike Bubalo Construction Co.,Inc. INSURER C:Hartford Casualty Insurance Company 29424
<br /> 5102 Gayhurst Ave. INSURER D:Sentinel Insurance Company, Ltd 11000
<br /> Baldwin Park,CA 91706 INSURER E:Indian Harbor Insurance Company 36940
<br /> INSURER F:
<br /> COVERAGES CERTIFICATE 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 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 ADOL SUBR POLICY NUMBER POLICY EFF POLICY EXP
<br /> LTR .NSD WVD (MM/DDIYYYYI (MM/DD/YYYYI LIMITS
<br /> A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000
<br /> CLAIMS-MADE X OCCUR X X 72UEABK2UA8 1/1/2025 1/1/2026 PREMISES((Enolccurrrence) $ 300,000
<br /> MED EXP(Any one person) $ 5,000
<br /> PERSONAL&ADV INJURY $ 1,000,000
<br /> GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
<br /> POLICY X PEOOT- LOC PRODUCTS-COMP/OP AGG $ 2,000,000
<br /> OTHER:
<br /> $
<br /> B AUTOMOBILE LIABILITY (Ea aBINEDf SINGLE LIMIT $ 1,000,000
<br /> X ANY AUTO X X 72UEACM5971 1/1/2025 1/1/2026 BODILYINJURY(Perperson) $
<br /> OWNED SCHEDULED -
<br /> _ AUTOS ONLY _ AUTOS BODILY INJURY(Per accidentL$ —
<br /> X HIRED X NON-OWNED PROPERTY DAMAGE
<br /> AUTOS ONLY _ AUTOS ONLY (Per accident) $
<br /> S
<br /> C X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 8,000,000
<br /> EXCESS LIAB CLAIMS-MADE X x 72HHABK2UF7 1/1/2025 1/1/2026 AGGREGATE $ 8,000,000
<br /> DED X RETENTION$ 10,000 $
<br /> D WORKERS COMPENSATION X MUTE EMPLOYERS'LIABILITY �,/N STATUTE ER
<br /> ANY PROPRIETOR/PARTNER/EXECUTIVE X 72WEABB8AXT 1/1/2025 11112026 E.L.EACH ACCIDENT S 1,000,000
<br /> OFFICER/MEMBER EXCLUDED? Y N/A
<br /> (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1'000'000
<br /> If yes,describe under 1,000,000
<br /> DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
<br /> E Professional E&O PEC001304022 1/1/2025 1/1/2026 Each Claim/Aggre 5,000,000
<br /> E Pollution Liab PEC001304022 1/1/2025 1/1/2026 Each Claim/Aggre 5,000,000
<br /> DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required)
<br /> PROJECT NO.:23-6627
<br /> ROUSSELLE STREET FLOOD PROTECTION PROJECT
<br /> City of Santa Ana,its City Council,officers,officials,employees,agents,and volunteers are included as Additional Insured with regards to General Liability
<br /> and Auto Liability,with coverage on a primary and non-contributory basis.Waivers of Subrogation apply in favor of additional insured with regards to General
<br /> Liability and Auto Liability and Workers Compensation.
<br /> APPROVED
<br /> By Tu Tran Nguyen at 11:31 am,Feb 05,2025
<br /> CERTIFICATE HOLDER CANCELLATION
<br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br /> City of Santa Ana THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br /> ACCORDANCE WITH THE POLICY PROVISIONS.
<br /> 20 Civic Center Plaza M-22
<br /> Santa Ana,CA 92701 Tii Tran DI9ItarlyN by yuy.n
<br /> Attn:Public Works Agency AUTHORIZED REPRESENTATIVE Nguyen Date:202S.o".os
<br /> I riI4/G1 G
<br /> ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved.
<br /> The ACORD name and logo are registered marks of ACORD
<br />
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