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A� b? CERTIFICATE OF LIABILITY INSURANCE
<br />DATE(MMIDDIYY )
<br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
<br />9/15/2014
<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(les) 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 endorsement(s).
<br />PRODUCER Patriot Risk & Insurance Services
<br />8105 Irvine Center Drive #400
<br />Irvine, CA 92618
<br />CONTACT
<br />PHONE 949 486-7900 AC No: 949 486-7950
<br />E-MAIL
<br />ADDRESS:
<br />INSURER(S) AFFORDING COVERAGE
<br />NAIC #
<br />9/1/2014
<br />INSURER A: Valley Fore Insurance Company
<br />205D8
<br />www.patrisk.com OG55454
<br />INSURED
<br />T. E. Roberts, Inc.
<br />INSURER B: Continental Casualty Company
<br />20443
<br />INSURER C: Torus National Insurance Company
<br />25496
<br />1131 E. Main Street, Suite 201
<br />INSURER D: Hartford Insurance Group
<br />$5,000 Deductible
<br />Tustin CA 92780
<br />INSURER E
<br />NSURER F
<br />PERSONAL &ADV INJURY
<br />COVERAGES CERTIFICATE NUMBER: 211976944 REVISION NUMBERi
<br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
<br />INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
<br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
<br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
<br />INSR
<br />LTR
<br />TYPE OF INSURANCE
<br />ADDLSUBR
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />POLICY NUMBER
<br />POLICY, EFF
<br />MMIOD YVVY
<br />POLICY EXP
<br />MMIDDIYYYY
<br />LIMITS
<br />A
<br />�/
<br />COMMERCIAL GENERAL LIABILITY
<br />CLAIMS -MADE F✓ OCCUR
<br />�/
<br />6014373100
<br />9/1/2014
<br />9/1/2015
<br />EACH OCCURRENCE
<br />$ 1,000,000
<br />Leonard E. Z minsky
<br />PREM IS (Ea occurrence) )
<br />$ 300,000
<br />✓
<br />MED ESP (Any one person)
<br />It 5,000
<br />$5,000 Deductible
<br />PERSONAL &ADV INJURY
<br />$ 1,000,000
<br />AGGREGATE LIMIT APPLIES PER:
<br />POLICY JEST LOC
<br />GENERAL AGGREGATE
<br />$ 2,000,000
<br />GEHL
<br />PRODUCTS-COMNOP AGG
<br />$ 2,000,000
<br />$
<br />OTHER:
<br />B
<br />AUTOMOBILE
<br />LIABILITY
<br />6014373114
<br />9/1/2014
<br />9/1/2015
<br />COMBINED SINGLE LIMIT
<br />Ea accident
<br />$ 1,000 000
<br />BODILY INJURY (Per person)
<br />$
<br />✓
<br />ANY AUTO
<br />ALL OS POPOBULEB
<br />AUTOS AUTOS
<br />BODILY INJURY Per accident
<br />( )
<br />$
<br />✓
<br />NON -OWNED
<br />HIRED AUTOS ✓ AUTOS
<br />PROPERTY DAMAGE
<br />(Peraccident)
<br />$
<br />A
<br />,/
<br />UMBRELLA LIAB
<br />I/
<br />OCCUR
<br />6014373128
<br />9/1/2014
<br />9/l/2015
<br />EACH OCCURRENCE
<br />$ 6,000 000
<br />AGGREGATE
<br />$ 6,000,000
<br />EXCESS LIAB
<br />CLAIMS -MADE
<br />DED RETENTION$
<br />$
<br />G
<br />WORKERS
<br />AND EMPLOYERS' LIABILITY YIN NSATION
<br />ANY PROPRIETORIPARTNEWEXECUTIVE
<br />OFFICERIMEMBER EXCLUDED? ❑
<br />(Mantlalory In NH)
<br />If yes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />NIA
<br />710140069
<br />9/1/2014
<br />>
<br />9/1/2015
<br />ERHr
<br />�/ STATUTE 10
<br />E.L. EACH ACCIDENT
<br />$ 1,000,000
<br />E.L. DISEASE -EA EMPLOYEE
<br />$ 1,000,000
<br />E.L. DISEASE -POLICY LIMIT
<br />$ 1,000,000
<br />D
<br />Inland Marine
<br />72UUMZD1671
<br />2/13/21014
<br />2/13/2015
<br />Rented/Leased Equipment: 100,000
<br />Deductible: $1,000
<br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
<br />Re:Agreement for On‐Call Sewer and Water System Repair Services throughout the City of Santa Ana, CA
<br />City of Santa Ana, its officers, employees, agents, volunteers and representatives are named as Additional Insureds, includes Primary and
<br />Non-contributory as respects to General Liability per endorsements attached where required by written contract.
<br />30 days notice of cancellation, 10 days for non-payment of premium.
<br />CERTIFICATE HOLDER CANCELLATION
<br />City Of Santa Ana
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />Public Works A enc Water Resources
<br />gPlaza
<br />THE EXPIRATION DATE THEREOF, NOTICE
<br />WILL BE DELIVERED IN
<br />20 Civic Center (M-30)
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />Santa Ana CA 92701
<br />AUTHORIZED REPRESENTATIVE f
<br />s
<br />Leonard E. Z minsky
<br />© 1988-2014 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
<br />CART NO.: 21$76944 Annette gomaro 9/15/2014 3:39:50 PM (PDT) Page 1 of 15
<br />TJ
<br />s certificate cancels and supersedes ALL previously issued certificates.
<br />
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