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ACOR" CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) <br /> 3/131 C <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 /> LibertyMutual Insurance Co. Nat'l Ins Northeast PHONE FAX <br /> 500 N3rd St, Suite 300 c AIc No): <br /> E-MAIL <br /> Wausau,WI 54403 ADDRESS: CMeCertProduction@LibertyMutual.com <br /> INSURERS AFFORDING COVERAGE NAIC# <br /> www.LibertyMutual.com INSURER A: Liberty Mutual Fire Insurance Company 23035 <br /> INSURED INSURER B: LM Insurance Corporation 33600 <br /> SULLY-MILLER CONTRACTING COMPANY <br /> 135 S.State College Blvd. INSURER C: <br /> Suite 400 INSURER D: <br /> Brea CA 92821 INSURER E: <br /> INSURER F: <br /> COVERAGES CERTIFICATE NUMBER: 84336107 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 ADDL SUBR POLICY EFF POLICY EXP <br /> LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMIODIYYYY MMIDDIYYYY LIMITS <br /> A �/ COMMERCIAL GENERAL LIABILITY �/ TB2-631-510805-025 4/1/2025 4/1/2026 EACH OCCURRENCE $2000000 <br /> DAMAGE TO RENTED <br /> CLAIMS-MADE ./ OCCUR PREMISES Ea occurrence $500 000 <br /> Per Job Aggregate MED EXP(Any one person) $10 000 <br /> IncludesXCU PERSONAL&ADV INJURY $2000,000 <br /> GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $3,000,000 <br /> POLICY� PEA LOC PRODUCTS-COMPIOPAGG $3 000,000 <br /> OTHER: $ <br /> A AUTOMOBILE LIABILITY AS2-631-510805-015 4/1/2025 4/1/2026 EOM�BIINdEeDISINGLELIMIT $2,000,000 <br /> ANYAUTO BODILY INJURY(Per person) $ <br /> OWNED SCHEDULED BODILY INJURY(Per accident) $ <br /> AUTOS ONLY AUTOS <br /> HIRED NON-OWNED PROPERTY DAMAGE $ <br /> AUTOS ONLY AUTOS ONLY Per accident <br /> UMBRELLA LIAB OCCUR EACH OCCURRENCE $ <br /> EXCESS LIAB CLAIMS-MADE AGGREGATE $ <br /> DED I I RETENTION$ $ <br /> B WORKERS COMPENSATION WC5-631-510805-035 4/1/2025 4/1/2026 �/ SPER TATUTE ERH <br /> AND EMPLOYERS'LIABILITY Y/N Covers All States <br /> ANYPROPRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT $2 000,000 <br /> OFFICER/MEMBER EXCLUDED? �N N/A <br /> (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $2 000 <br /> .000 <br /> If yes,describe under <br /> DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1 $2 000 000 <br /> A Automobile Physical Damage: AS2-631-510805-015 4/1/2025 4/1/2026 <br /> All Medium, Heavy,Extra Heavy and Trailer Types Comp&Coll Deds:$1,500 <br /> "All Private Passengers, Pick Ups and Vans Comp&Coll Deds:$500 <br /> DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) <br /> RE:Project No.11-6741 Bristol Street Improvements from Warner Avenue to Saint Andrew Place and Project No.:19-6499 Bristol Street(Phase 4) <br /> Water Main <br /> "See Addendum" <br /> Digill",signe <br /> Tu Tran Nguyen APPROVED <br /> N(ryu en° 8 Tu Tran Nguyen ai 9:24 am,Apr 07,2025 <br /> 7 Y 2025.04.07 YP <br /> 09:24.48-0700 <br /> CERTIFICATE HOLDER CANCELLATION <br /> Job10340704 <br /> CI of Santa Ana SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br /> City THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br /> City Hall - Ross Annex ACCORDANCE WITH THE POLICY PROVISIONS. <br /> 20 Civic Center Plaza <br /> Santa Ana CA 92701 <br /> AUTHORIZED REPRESENTATIVE <br /> Diane Beaudoin <br /> ©1988-2015 ACORD CORPORATION. All rights reserved. <br /> ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD <br /> 84336107 1 3-004090 1 4/25-4/26 - Sully Miller I Julie Nelson 1 3/13/2025 8:58:32 AM (EDT) I Page 1 of 2 <br />