|
•� ® DATE(MMIDDNM)
<br />!!`r© CERTIFICATE OF LIABILITY INSURANCE 06/1812019
<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 INSURERS), AUTHORIZED
<br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
<br />IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) 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 Ileu of such endorsements .
<br />PRODUCER Bill Douglas KDuria insurance Agency,lnc NAME:
<br />10345 Danichris Way PHO E 918-*36-5641 916-685-9571
<br />Elk Grove CA 95757 ! M19L . bdklnsurance0amall.com a
<br />INSURER A • Houston Casualty Company 142374
<br />INSURED Bender Rosenthal, Inc. •• INSURER B: ravelers Property Casualty Co of America 26674
<br />2625 Watt Avenue, Suffe 200 INSURERCs
<br />Sacramento CA 95821
<br />INSURER Dt
<br />INSURER E :
<br />INSURER P t
<br />r nVFRAr.FS r:PRTIPN".ATF NI IMRFR� Ranlacas cart dated n510112019 RFVIRIn1J NIIMRf"R. 4
<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 />INsh /io0t. sbaR PQLIC EFF P6Licr RRP
<br />L TYPE OFINSURANCE INSO wvD POLICY NUMBER MMMDNYYY1 LIMITS
<br />B
<br />JCOMMERCIAL0ENERALLIABILITY
<br />CLAIMS-MADE ✓ OCCUR
<br />z/V/EACH
<br />630-OK104459-TIL-19
<br />6/0112019
<br />06/0112020
<br />OCCURRENCE
<br />-6AIUAOE'ro"1 TFb---
<br />P.REM.IS6S (I:a uccunenco)
<br />S1,000,000
<br />•---_----
<br />S100,000---
<br />-----------
<br />MEDEXP(Anyone (son),
<br />$5,000
<br />PERSONAL aADVINJURY
<br />$1,000,000
<br />GEN1AOeA£G TELIMITAPPLIESPER:
<br />POLICYlJ JECTPRO. Ej LOC
<br />_GENE_RALAOGREGATE _
<br />PRODUCTS-COMPIOPAGG
<br />_S2,000,o_oo__
<br />2,000,000
<br />$
<br />OTHER:
<br />AUTOMOBILE LIABILITY
<br />k
<br />�/
<br />M I DS LELMI
<br />$1,000,000
<br />BODILY INJURY (Per pamon)
<br />�/ ANY AUTO
<br />S
<br />B
<br />OWNED SCHEDULED
<br />__ AUTOS ONLY AUTOS
<br />✓ HIJRTosONLY ✓ NON-OWNED
<br />ON-OWAUTOS N D
<br />IBA-9K106686-19-14
<br />1)61011201g
<br />0610112020
<br />BODILY INJURY (Per accident)
<br />S
<br />PR RTy� nainGE
<br />s -
<br />EACH OCCURRENCE
<br />S 5,000,000
<br />06IF0112019
<br />0610112020
<br />B
<br />UMBRELLALIAB OCCUR
<br />✓
<br />✓
<br />EX-91(117560-19-14
<br />V
<br />EXCESS LIAO CLAIMS.MAOE
<br />f
<br />GL, Auto and WC form
<br />AGGREGATE
<br />$5,000,000
<br />— —
<br />DED RETENTIONS
<br />_ _
<br />16101120111
<br />06/0112020
<br />OTH-
<br />✓ 7ATUTE 9&
<br />s
<br />B
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY YiN
<br />OFCEWAEMORIPAR UDEEXECUTIVE D
<br />(Mandatory In NH)
<br />NIA
<br />LI
<br />UB-91<107321-19-14
<br />E.L EACH ACCIDENT
<br />$1,000,000
<br />E.LDISEASE- EAEMPLOYEE
<br />S1,000,000
<br />Usa describe under
<br />RIPTION OF OPERATIONS below
<br />I
<br />E.L. DISEASE -POLICY LIMIT
<br />I S1,000,000
<br />A
<br />�CLAIMSMADE
<br />Professional Lleblllty
<br />QQ
<br />H718-112596
<br />Deductible 15,000
<br />11130/2,018 11113012019
<br />0 Per
<br />12,000 ooDAggrsgaleenc
<br />E10
<br />Retro Date 11130/99
<br />DESCRIPTION OF OPERATIONS 1 LOCCof WaypAnONB (VEHICLES (ACOROO t01, Additional Rumurka aehedule. may bo ottouhod I f mora space Is requlrod)
<br />Days for Non -Payment IL02700912
<br />30 Days Notice of Job: On -Call Cotract, Project For ritten Contract
<br />INSUREDIPRtrhARritten
<br />COMMERCIALIght GENEIRAL L A131LpraTY BLANKET ADDITIONAL Y1NON•CONTR[BUTORYfWAIVER OF SUBROGATIONIHOLD
<br />HARMLESSIINSUREDS-SUBCONTRACTOR, OUR WORK PER PROJECT OR LOCATION: CGD2460805 Per Written Contract
<br />COMMERCIAL AUTO BLANKET ADDITIONAL INSUREDIPRIMARY/WAIVER OF SUBROGATIONIEMPLOYEES AS INSUREDS: CAT3530216 Per
<br />Written Contract. WORKERS' COMPENSATION WAIVER OF SUBROGATION: WC990376(A)-001 For Written Contract
<br />UMBRELLA. Any Person Qualifying as such under underlying General Liability, Commercial Auto, and Workers' Compensatlon insurance.
<br />Additional Insured: City of Santa Ana, Its officers, employees, agents, volunteers, and representatives
<br />CERTIFICATE HOLDER CANCELLATION
<br />City of Santa Ana
<br />Risk Management Division
<br />20 Civic Center Plaza
<br />Santa Ana, CA 92702
<br />ACORD 25 (2016/03)
<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 />01988.2015 ACORD CORPORATIO All righ! resew d.
<br />The ACORD name and logo are registered marks of ACORD
<br />Produced uslna Forma Bose Web Software, www.FormaBosa,com tat Imoreselve Publlshlna 800-208.1971
<br />F KCVI'CVVCLJD1;
<br />IAA+
<br />15k M nag ant Ivlsion
<br />
|