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<br />,AC"R" CERTIFICATE OF LIABILITY INSURANCE DATE (PA M/DD/ 16
<br />tom__.,, 10/13/2016
<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 the
<br />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 CONTACT
<br />NAME _
<br />WILLIS OF ILLINOIS, INC. PHONE FAx ---
<br />AMC, No. Ext).- (888) 780-5381 1_tAIC No) (877) 737-8498_
<br />233 S WACKER DR,SUITE 2000 ADDRESS: Certificate@hanover.com _
<br />CHICAGO IL 60606 --
<br />'
<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 />INSURER(S) AFFORDING COVERAGE
<br />_..
<br />NAIC ;f
<br />GENERA LIABILITY
<br />INSURER A
<br />-^--............
<br />_....._.......... ...---- .-..-..-----
<br />Citizens Ins Cc of America
<br />'
<br />31534
<br />INSURED
<br />COMMERCIALGENERAL LI BILI Y
<br />X COL
<br />X
<br />INSURER B:
<br />Hanover American Ins Co
<br />36064
<br />BUCKNAM INFRASTRUCTURE GROUP
<br />��
<br />I
<br />----_.-..
<br />09/16/2016 09/16/2017
<br />MED EXP (Any one person) 5 10 000
<br />_
<br />INSURER C:
<br />I
<br />PERSONAL &ADV INJURY S_ 1 000,000
<br />INC
<br />_ _
<br />C'Et^lERAL AGGREGATE s2,000,000
<br />. _
<br />.
<br />G N'LAGGIR GATELIMITAPP_LIE5PER I
<br />INSURER p ;
<br />j
<br />2,000,00 --.
<br />PRODUC.IS-COMPIOPAGG O
<br />3548 SEAGATE WAY SUITE 230
<br />..�
<br />X PROT
<br />_--_-
<br />Il
<br />t .-___- -.
<br />PULICY JECLOC
<br />INS-URER--_-E
<br />OCEANSIDE, CA 92056
<br />�—
<br />COMBINFD SINGLE LIMIT
<br />Ea accideno _____3 1,000,000
<br />BODILY INJURY
<br />ANY AUTO
<br />(Per person) S
<br />A - ALL OWNED SCHEDULED
<br />INSURER F
<br />BODILY INJURY {Per accident) S
<br />_—� AUTOS AUTOS
<br />X NON-0N.TIED
<br />__... HIRED AUTOS - X_ AUTOS
<br />rr)VFRAr,Fs CERTIFICATE NUMBER:
<br />_
<br />PROPERTY DAMAGE --- --��---__-..
<br />{Per acddent) a ------
<br />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�-- ----_ ADDL SUER; POLICY EFF-. POLICY EXP. -------._._.
<br />LTR TYPE OF INSURANCE J POLICY NUMBER h1 M1DD/YYYY MMIDDIYYYY LIMITS
<br />GENERA LIABILITY
<br />1
<br />EA II OCCURRENCE s 1,000,000
<br />DAMAGE 10 Rf NTc.D 1 — -- -
<br />COMMERCIALGENERAL LI BILI Y
<br />X COL
<br />X
<br />i
<br />PREMISES (Ea occurr n_ t o 1,000,000
<br />A_.A.
<br />��
<br />I
<br />{
<br />OBC A399956 02
<br />09/16/2016 09/16/2017
<br />MED EXP (Any one person) 5 10 000
<br />_
<br />I
<br />PERSONAL &ADV INJURY S_ 1 000,000
<br />_ _
<br />C'Et^lERAL AGGREGATE s2,000,000
<br />. _
<br />.
<br />G N'LAGGIR GATELIMITAPP_LIE5PER I
<br />j
<br />2,000,00 --.
<br />PRODUC.IS-COMPIOPAGG O
<br />..�
<br />X PROT
<br />Il
<br />t .-___- -.
<br />PULICY JECLOC
<br />AUTOMOBILE LIABILITY
<br />�—
<br />COMBINFD SINGLE LIMIT
<br />Ea accideno _____3 1,000,000
<br />BODILY INJURY
<br />ANY AUTO
<br />(Per person) S
<br />A - ALL OWNED SCHEDULED
<br />OBC A399956 02 j 09/16/2016 09/16/2017
<br />BODILY INJURY {Per accident) S
<br />_—� AUTOS AUTOS
<br />X NON-0N.TIED
<br />__... HIRED AUTOS - X_ AUTOS
<br />�`
<br />_
<br />PROPERTY DAMAGE --- --��---__-..
<br />{Per acddent) a ------
<br />1S
<br />X UMBRELLA LIAR X - iX'
<br />CLAIMS
<br />EACH OCCURRENCE S 9,000,000
<br />A E SS LIAB CLAIMS:MADE
<br />OBC A399956 02 09/16/2016 09/16/2017
<br />_--$9,000,000---
<br />AC GRE9f TE !
<br />_-� ... ...------
<br />-. CEO I RETENTION S
<br />____.__- ....._-..
<br />S
<br />I WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY
<br />X TO Y l UFR.I,,,,.._ -
<br />ANY PROPRIETOR/PAR'rNERIC'XE'CUTIVr= y / N
<br />B OFFICE MEMBER EXCLUDED9 n N I A
<br />Ij X WZC A399946 02 09/16/2016 09/16/2017
<br />L F L EACH i ACCIDENT S 1,000,000
<br />(Mandatory In NH)
<br />E.L.-DISEASE - EA EMPLOYEE S 1,000,000
<br />if yes, describa under
<br />D_r,1Q.RjPTIQN OF .ATONS b.10.1
<br />_..___. ..............._-_ ...........-___
<br />E L DISEASE - POLICY LIMW1 � 8 1,000,000
<br />�
<br />I
<br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, I'more space is required)
<br />The City of Santa Ana, its officers, employees, agents, volunteers and representatives are Additional Insured on the General Liability as their interest may appear in regard to
<br />work performed or services provided by the Named Insured pursuant to the terms and conditions of form: BP0450 (Additional Insured -Owners, Lessees or Contractors).
<br />Waiver of subrogation on Workers Compensation as provided by: WC040306 (California Form).
<br />'e7
<br />R.EV9EWED BY:r "� EUNICE HEREDIA (PG OF }
<br />I.CK I It -[(,A It MULUCK l-kkNk.CLLA I IVN
<br />72ic
<br />ty of Santa Ana
<br />Center Plaza M-36 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />Ana CA 92701 ACCORDANCE WITH THE POLICY PROVISIONS.
<br />AUTHORIZED REPRESENTATIVE
<br />O 1988-2010 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD
<br />
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