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® DATE(MMIDDfYYYY)
<br />ACC)�_. CERTIFICATE OF LIABILITY INSURANCE 01130r2017
<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 pollcy(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 CT' Chris Rudolph
<br />Triton of Calif Insurance Services, Inc. PHONE FAX
<br />2332 Auburn Blvd ..E,�)PINP,.,Ia�ttr: I916)485 17p5 Nal�(916)485.0195
<br />Sacramento, CA 95821
<br />ADDRESS:... Chris aitritoninsurance.com _..
<br />-. .—.
<br />License #: OF41767 INSURER(S)AFFORDING .COVERAGE . NAIL#..
<br />.. INSURER A : Mesa Underwriters Speciality Insurance Co, ..... ....
<br />INSURED TOM BYSTRY m'µ "�.. r� INSURER. B. _... _...
<br />DBA: VIDEO ENGINEERING SERVICES INSURER C
<br />16875 DONWEST INSURERot
<br />TUSTIN, CA 92780 INSURER E:
<br />INSURER F
<br />COVFRACFS CFRTIFIrATF NIIrW1RFR• nnnnnnnn.ldK{K RFVIglnN NIIIru1Rl=P- 17'
<br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAME? 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 iAOOL SUBR.. POLICY EFF 1 POLICY EXP _ _. ........
<br />LTR TYPE OF INSURANCE POLICY NUMBER MMIODIYYYY MM/Od7/YYYY LIMITS
<br />A X COMMERCIAL GENERAL LIABILFTY Y Y MPaa04009002994 10210112017 1 02101/2018 EACH OCCURRENCE 5 1.,000,000
<br />,
<br />I CLAIMS -MADE X ',.... OCCUR .. - DAMAGE TO RENTED
<br />PREMISES [Ea occurrence)._..... $ 1 00,00a
<br />MED EXP (Any one person) $ 51000
<br />__ ._... PERSONAL BADVINJURY $ 1_,000,000
<br />GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
<br />X POLICY I PRO- JECT LOC PRODUCTS - COMP/OP AGG... S 2,000,000
<br />I
<br />OTHER:
<br />AUTOMOBILE
<br />LIABILITY COMBINED SINGLE LIMIT $
<br />(Eaaccident)
<br />ANY AUTO BODILY INJURY (Per person) $
<br />H
<br />SCHE
<br />OWNED AUTODULED..-.. BODILY INJURY (Per accident) $
<br />AUTOS ONLY AUTOSHARED
<br />NON -OWNED PROPERTY DAMAGE$
<br />AUTOS ONLY AUTOS ONLY '... (Per. accident) _.
<br />+.:,, $
<br />UMBRELLA LIAR s
<br />OCCUR � � EACH OCCURRENCE $
<br />HCLAIMS-MADE
<br />EXCESS LIAB AGGREGATE $
<br />..._
<br />DED RETENTIONS $
<br />WORKERS COMPENSATION "^ "��' ✓:%*" {uS,. PER OTH-
<br />AND EMPLOYERS' LIABILITY YIN ., ,o;�'� STATUTE ER ....... ........... _
<br />ANY PROPRIETORfPARTNERIEXECUTIVE o E L EACH ACCIDENT $
<br />❑ N / A ..
<br />r
<br />OFFICER/MEMBER EXCLUDED? Y'
<br />(Mandatory In NH) .t�' i f'3 ' y' 9. EL DISEASE - EA EMPLOYEE $
<br />,,...:
<br />.,.B
<br />I If yes describe under
<br />.. DESCRIPTION OF OPERATIONS below "4,P^ "°" - E..L.. DISEASE -POLICY LIMIT S
<br />i
<br />DESCRIPTION OF OPERATIONS I LOCATIONS r VEHICLES (ACORD 101, Additional Remarks Schedule„ maybe attached If more space is required)
<br />The City of Santa Ana, 20 Civic Center Plaza, Santa. Ana, California 92701; it officers,
<br />employees, agents and representative are named as additional insureds ("additional
<br />insureds") with regard to liability and defense of suits arising from the operations and uses
<br />performed by or on behalf of the named insured. With respect to claims arising out of the operations and uses performed by
<br />or on behalf of the named insured, such insurance as is afforded by this policy is primary and is not additional or contributing
<br />with any other insurance carried by or for the benefit of the additional insureds. This insurance applies separately to each
<br />continued on ACORD 101 Additional Remarks Schedule
<br />CITY OF SANTA ANA, IT'S OFFICERS, EMPLOYEES, AGENTS AND
<br />REPRESEN
<br />20 CIVIC CENTER PLAZA M-16
<br />Santa. Ana,, CA 92702
<br />t;AN4:kLLA I IUN
<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 />@ 1988-2015 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
<br />Printed by CPR on January 30, 2017 at t 2:25PM
<br />
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