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LEXIP-1 OP ID: CL
<br />'4� ap CERTIFICATE OF LIABILITY INSURANCE
<br />DATE/251201 rv)
<br />08/25/2015
<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 />fj,T I ATE LtheER
<br />REPRESENTATIVE OR PRODUCER, AND TKA
<br />T
<br />IMPORTANT: If the certificate holder is a'N 'L IN f) ED, policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
<br />the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
<br />certificate holder in lieu of such endorse Cs y ;:.v
<br />PRODUCER , [}I.
<br />RBN &Associates, Inc. j,,�,.,_
<br />303 East Wacker Dr Suite 1130
<br />Chicago, IL 60601
<br />Bruce Scodro
<br />CONTACT
<br />NAME: Cyndi LaMotte
<br />Alc° No B,1,312-856-9400FAAic No
<br />E-MAIL
<br />ss: clamotte@rbn5OO.com
<br />A
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />CLAIMS -MADE ® OCCUR
<br />INSURERS AFFORDING COVERAGE
<br />NAIC#
<br />INSURERA: Capitol Specialty Insurance Co
<br />08/20/2015
<br />08/20/2016
<br />INSURED Lexipol Holding Company
<br />Lexipol, LLC
<br />6 B Liberty, Ste 200
<br />INSURER B: Hartford Insurance Group
<br />DAMAGE TO REN
<br />PREMISES Ea o-TEU ce $ 300,00
<br />INSURER C: Hiscox Insurance Co. Inc.
<br />MED EXP (Any one person) $ 6,00
<br />Aliso Viejo, CA 92656
<br />INSURER D:
<br />INSURER E:
<br />INSURER F:
<br />PERSONAL& ADV INJURY $ 1,000,00
<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
<br />LTR
<br />7ypE OF INSURANCE
<br />ADDL
<br />D
<br />SUER
<br />VAID
<br />POLICYNUMBER
<br />POLICY EFF
<br />MMIDDIYYW)
<br />POLICY EXP
<br />(MMIDDNYYYI
<br />LIMITS
<br />A
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />CLAIMS -MADE ® OCCUR
<br />BR02669604-01
<br />08/20/2015
<br />08/20/2016
<br />EACH OCCURRENCE $ 1,000,00
<br />DAMAGE TO REN
<br />PREMISES Ea o-TEU ce $ 300,00
<br />MED EXP (Any one person) $ 6,00
<br />PERSONAL& ADV INJURY $ 1,000,00
<br />AGGREGATE LIMIT APPLIES PER:
<br />POLICY PRO- ❑
<br />ECT LOC
<br />GENERAL AGGREGATE $ 2,000,00
<br />GEN'L
<br />X
<br />PRODUCTS - COMP/OPAGG $ Excluded
<br />$
<br />OTHER:
<br />AUTOMOBILE
<br />LIABILITY
<br />COMBINED SINGLE LIMIT
<br />Ea $ 1,000,00
<br />accident
<br />BODILY INJURY (Per person) $
<br />ANY AUTO
<br />83 SBA IM3110
<br />08/20/2015
<br />08/20/2016
<br />ALL OWNED SCHEDULED
<br />AUTOS AUTOS
<br />ttl
<br />Per accident)
<br />BODILY INJURY ( ) $
<br />X
<br />HIRED AUTOS X NON -OWNED
<br />AUTOS
<br />PROPERTY DAMAGE $
<br />Per accitlent
<br />UMBRELLA LIAB
<br />X
<br />OCCUR
<br />EACH OCCURRENCE $ 5,000,00
<br />X
<br />AGGREGATE $ 5,000,00
<br />A
<br />EXCESS UAB
<br />CLAIMSMADEBR02569504-01
<br />08/20/2015
<br />08/20/2016
<br />X
<br />DED RETENTION$ 0
<br />$
<br />B
<br />WORKERS COMPENSATION-
<br />AND EMPLOYERS' LIABILITY
<br />ANY PROPRIETOR/PARTNER/EXECUTIVE YIN
<br />OFFICER/MEMBER EXCLUDED?
<br />(Mandatory in NH)
<br />NIA
<br />83 WEC BZ5648
<br />08/20/2015
<br />08/20/2016
<br />X PER OTH-
<br />STATUTE ER
<br />E.L. EACH ACCIDENT $ 1,000,00_
<br />E.L. DISEASE - EA EMPLOYEE $ 1,000,00
<br />If yes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />E.L. DISEASE -POLICY LIMIT $ 1,000,00
<br />C
<br />Professional Liabl
<br />US UUA 2688184.15
<br />08/20/2015
<br />08/20/2016
<br />Ea Claim 3,000,00
<br />Multimedia Liab
<br />Aggregate 3,000,00
<br />DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if mare space Is required)
<br />The City of Santa Ana and Santa Ana Police Department, their officers,
<br />emplo ees agents and volunteers are Additional Insureds as respects General
<br />Liability as required by a written contract or written agreement.
<br />SANTAAN
<br />City of Santa Ana
<br />Santa Ana Police Department
<br />20 Civic Center Plaza
<br />Santa Ana, CA 92702
<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 />Z5�p_
<br />01988-2014 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
<br />
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