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SAMBSAF-01 BSTIERWALT <br />ACORO CERTIFICATE OF LIABILITY INSURANCE <br />�..•-'••� <br />DATE <br />1012112 V015 <br />1 012112 5 <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, EXpTIEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES <br />BELOW. THIS CERTIFICATE OF INSURANCE DOES IyN1f''IVTrTI"TIT �NT+RACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED <br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER'. L!' <br />IMPORTANT: If the certificate holder is an ADDITIOI S4RgDt-thepolicy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to <br />the terms and conditions of the policy, certain policie s y egibili'e ar 4,4k j�o r♦,eritl A statement on this certificate does not confer rights to the <br />certificate holder in lieu of such endorsement(s). <br />,UVNI <br />PRODUCER License # 0757776 <br />HUB International Insurance Services (NMX) <br />7770 Jefferson Street NE <br />Suite 101 <br />Albuquerque, NM 87109 <br />clNAME-- <br />PHONN ,(505 828-4000 AIC, No : (866) 487-3972 <br />EMAIL <br />AOORESS: <br />INSURER(S)AFFORDING COVERAGE NAICa <br />INSURER A : Sentinel Insurance Company, Ltd. 11000 <br />X <br />INSURED <br />INSURERS: Hartford Casualty Insurance Company 29424 <br />Samba Safety Holdings, LLC <br />INSURER c: Hartford Fire Insurance Company 19662 <br />and Samba Holdings, Inc <br />8814 Horizon Blvd NE #100 <br />INSURER D: <br />INSURER E: <br />Albuquerque, NM 87113 C I,. <br />N'a�15•)b� <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 <br />LTR <br />TYPE OF INSURANCEADDLSUBR <br />INSD <br />MD <br />POLICY NUMBER <br />POLICY EFF <br />MMIDDIYYYY <br />POLICY EXP <br />MMIDDNYYV <br />LIMITS <br />A <br />X <br />COMMERCIAL GENERAL LI ABILITY <br />EACH OCCURRENCE $ 1,000,000 <br />CUIMS-MADE ® OCCUR <br />34UUNAQ2525 <br />08/31/2015 <br />08/3112016 <br />PREMISES EaraEocc�urrenca $ 300,000 <br />MED EXP (Any one person) $ 10,000 <br />PERSONAL&ADV INJURY $ 1,000,000 <br />° <br />CENT AGGREGATE LIMIT APPLIES PER: <br />GENERALAGGREGATE$ 2,000,000 <br />POLICY D PRO- JECT LOC <br />__---..-_.._......._._ _ <br />PRODUCTS - COMP/OPAGG $ 2,000,000 <br />OTHER: <br />AUTOMOBILE <br />_ <br />LIABILITY <br />COMBINED SINGLE LIMIT $ 1,000,000 <br />Ea accident) <br />BODILY INJURY (Per person) $ <br />A <br />X <br />ANY AUTO <br />34UUNAQ2525 <br />08/31/2015 <br />08/3112016 <br />ALL OWNED SCHEDULED <br />AUTOS AUTOS <br />BODILY INJURY (Per accident) $ <br />_ <br />PROPERTY DAMAGE $ <br />Peraccident <br />XX <br />NON -OWNED <br />HIREDAU70S AUTOS <br />X <br />UMBRELLA LIAB <br />OCCUR <br />EACH OCCURRENCE $ 14,000,000 <br />AGGREGATE $ 14,000,000 <br />B <br />EXCESS LIAR <br />CLAIMS -MADE <br />34RHUAQ1596 <br />08/31/2015 <br />08/31/2016 <br />DEO X I RETENTION$ 10,000 <br />$ <br />C <br />WORKERS COMPENSATION <br />ANDEMPLOYERS'LIABILITY <br />ANY PROPRIETOR/PARTNERIEXECUTIVE YIN <br />OFFICERIMEMBER EXCLUDED? El <br />(Mandatory In NH) <br />N/A <br />34WECB1180 <br />10/01/2015 <br />10101/2016 <br />X PER OTH- <br />STATUTE ER <br />E.L.. EACH ACCIDENT $ 1,000,000 <br />E.L. DISEASE - EA EMPLOYE $ 1,000,000 <br />If yes describe under <br />DESGIRIPTION OF OPERATIONS below <br />E.L. DISEASE -POLICY LIMIT $ 1,000,00 <br />DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required). <br />Tech E&O/Cyber E000117666 813112015.8/3112016 $5M <br />Tech E&O/Cyber MAN789372012015 8/3112015 - 8/31/2016 $5M/in excess of $5M <br />Tech E&O/Cyber QPL0119610 8131/2015 - 8/3112016 $5M1in excess of $10M <br />Where required by written contract or agreement City of Santa Ana is Included as additlonal insured with respects to general liability per attached form <br />HG0001 0605. Workers Compensation coverage is evidence only. <br />City of Santa Ana <br />20 Civic Center Plaza <br />Santa Ana, CA 92701 <br />ACORD 25 (2014101) <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 />©1988-2014 ACORD CORPORATION. <br />The ACORD name and logo are registered marks of ACORD <br />