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SAMBSAF-01 BSTIERWALT
<br />ac�Rr� CERTIFICATE OF LIABILITY INSURANCE
<br />�-�
<br />DATE(MIY)
<br />8122!1209201Y6
<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 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 License # 0757776
<br />HUB International Insurance Services (NMX)
<br />7770 Jefferson Street NE
<br />Suite 101
<br />CONTACT
<br />NAME, Barbara Stierwalt
<br />PHONE 823,4939 F°x
<br />vc No E4:(505) arc No :
<br />SS: barbara.stierwalt@hubinternational.com
<br />ADDRESS:
<br />Albuquerque, NM 87109
<br />34UUNZG6992
<br />I
<br />0412812016
<br />INSURER(S) AFFORDING COVERAGE NAIC #
<br />INSURER A: Hartford Fire Insurance Company 19682
<br />INSURED
<br />INSURER B: Hartford Casualty Insurance Company 29424
<br />Samba Safety Holdings, LLC
<br />INSURER C: Hartford Ins Co of the Midwest 37478
<br />and Samba Holdings, Inc
<br />8814 Horizon Blvd NE #100
<br />INSURER D
<br />INSURER E:
<br />Albuquerque, NM 87113
<br />INSURER F:
<br />$
<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 RESPECTTO 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 />ILSRR
<br />TYPE OF INSURANCE
<br />NSD
<br />WVD
<br />POLICY NUMBER
<br />POLICYEFF
<br />MMILICY EXP
<br />LIMITS
<br />A
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />CLAIMS -MADE FKOCCUR
<br />X
<br />I
<br />34UUNZG6992
<br />I
<br />0412812016
<br />04128/2017
<br />EACH OCCURRENCE $ 1,000,000
<br />DAMAGE TO RENTED 300 00
<br />PREMISES Ea occurrence $ ,
<br />MED EXP (Any one person) $ 10,000
<br />GEN'L
<br />PERSONALS ADV INJURY $ 1,000,400
<br />AGGREGATE LIMIT APPLIES PER
<br />POLICY PRO-
<br />JECT LOC
<br />OTHER:
<br />GENERAL AGGREGATE $ 2,000,000
<br />PRODUCTS-COMPIOPAGG $ 2,000,000
<br />$
<br />A
<br />AUTOMOBILE LIABILITY
<br />X ANY AUTO
<br />ALL OWNED SCHEDULED
<br />AUTOS AUTOS
<br />NON -OWNED
<br />X HIRED AUTOS X AUTOS
<br />34UUNZG6992
<br />04/28/2016
<br />04128!2017
<br />EOa aBINEDtSINGLE LIMIT $ 1,000,000
<br />BODILY INJURY (Per person) S
<br />BODILY INJURY Per accident $
<br />( )
<br />PROPERTY DAMAGE
<br />Peraccident $
<br />B
<br />X UMBRELLA LIAB
<br />EXCESS LIAQ
<br />HCLAIMS-MADE
<br />OCCUR
<br />34XHUZG5840
<br />04128/2016
<br />04/28/2017
<br />EACH OCCURRENCE $ 14,000,000
<br />AGGREGATE $ 14,000,000
<br />DED X RETENTIONS 14,000
<br />$
<br />C
<br />WORKERS COMPENSATIONPER
<br />AND EMPLOYERS' LIABILITY
<br />ANY PROPRIETORIPARTNERIEXECUTIVE YIN
<br />OFFICERIMEMBER EXCLUDED? ❑
<br />{Mandatary in NH)
<br />If yes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />N I A
<br />34WECE8877
<br />0412812016
<br />0412812017
<br />OTH-
<br />X STATUTE ER
<br />E.L. EACH ACCIDENT $ 1,000,00
<br />E.L. DISEASE- EA EMPLOYEd $ 1,000,000
<br />E.L. DISEASE- POLICY LIMIT I $ 1,000,000
<br />1
<br />7
<br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required)
<br />Entity names include:
<br />Safety Intermediate Holdings ll, Inc; Safety Holdings Inc; American Driving Records, Inc (ADR); Samba Holdings, Inc; Softech International Inc.
<br />Where required by written contract or agreement City of Santa Ana is included as additional insured with respects to general liabiilty per attached form
<br />HG0001 0605. Workers Compensation coverage is evidence only.
<br />CERTIFICATE HOLDER CANCELLATION
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />City Civic Center Plaza of Santa Ana THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />20
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />Santa Ana, CA 92701
<br />AUTHO
<br />RIZED REPRESENTATIVE
<br />I
<br />c4d
<br />©1988-20'14 ACORD CORPORATION. Ali rights Pf',
<br />ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD , l j�
<br />
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