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CERTIFICATE OF LIABILITY INSURANCE
<br />DATE (MM1DDlYYYY)
<br />3/16/2017
<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(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 lieu of such endorsement(s).
<br />PRODUCER Phone: (707)996-2912
<br />CONTACT jeHl e Lewis
<br />Pax: (7(17)9'76-7912
<br />Apollo General Insurance Agency, Inc. (I)
<br />NAME: __
<br />PHONE F - --- --
<br />FAX
<br />�-
<br />P. 0, Box 1508
<br />ADD iESS; jerilc�l a,alrgen.com
<br />Sonoma, California 95476
<br />INSURERS AFFOR DING COVERAGE
<br />NAI({!
<br />ItttcfS(Ltte hire & Casualty CDnipally
<br />22829
<br />—_INSURERA:
<br />INSURED
<br />— -----.._--'---
<br />INSURER B: AmericanAUtU1T10b11e .InsttranDc Company
<br />21849
<br />I&G Industries Inc,
<br />..INSURER c_ Philadelphia Insurance Company
<br />23850
<br />1862713rookhulStStreet.
<br />35076
<br />INSURER D State Compensation InsuranUc Land O1( tiifotaia
<br />P%,TB 302
<br />— -- --
<br />Fountain Valley, CA 92708
<br />INSURERE: Westchester Surplus Lin -s Insu anCQ, 01 111
<br />1 172
<br />©
<br />__.
<br />INSURER F:
<br />COVERAGES CERTIFICATE NUMBER: 707 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'1'O
<br />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 .-__.._....AUDI"SU6ft''-._--_------'-_____-----
<br />LTR TYPE OP INSURANCE POLICY EFF POLICY EXP------`-�'
<br />SD (yVVO POLICY NUtdBER MM/DbM(YY MMIDDfYYYY LIMITS
<br />✓ COMMERCIAL GENERAL LIABILITY
<br />DANI00t)456
<br />11/1/2fj16
<br />11/1/2017
<br />EACHOCCURREN('E�S
<br />'—"-'- --'—"
<br />1 000,000
<br />A
<br />- -
<br />CLAIMS MADE I ✓ � (^(.,CUft--
<br />�
<br />_
<br />3(j0, 000
<br />�
<br />'yIED EXP (Ir y or�n {Eur�cn�
<br />_ _
<br />u
<br />—
<br />PERSONAL &ADV INJUIRY a 1 000,000
<br />I
<br />GEN'!_ AGGREGATE L IMIr 1PPLIESPER
<br />PRO r
<br />l
<br />GENERAL AGGREGAtE y 2,0"00,"000-
<br />0 0(70
<br />�FRODUCTS-COrAP/CP AGG� $ ...--... 2,00 0000,
<br />_ POLICY LOC
<br />�'
<br />OTHER:
<br />AUTOMOBILE LIABILITY
<br />^dY
<br />'0:YA80321760
<br />I1/1/2016
<br />11/1/2017
<br />Cor,lala:DSINGLE LIMT $ 1,000,000
<br />L _._
<br />✓ A AUTO
<br />_
<br />i BODILY INJURY (Per persar) ( 3
<br />7SCHECULED
<br />AUTOS
<br />1
<br />....-
<br />INJURY (Foric <ie t-) f
<br />✓ O�
<br />`
<br />......
<br />IrROPLRIAUTOS0NLY E E
<br />4C —✓-1 —
<br />AUTONLY
<br />rr. r eYrUAMA--'O
<br />C
<br />UMBRELLA ✓ OCCUR
<br />EXCESS LABIAB—� - < u Ms rtADli
<br />r .,
<br />PIJI35621t3
<br />11/1/2016
<br />11/1/2017
<br />A0lrocruRRtNCF s 2,00t),0001
<br />_
<br />� AGGREGATE ---�---- i --.......-2 )
<br />s ,0t 0,000
<br />DED RETENTION S r
<br />)
<br />PCr accident S 2,000,0001
<br />'
<br />D
<br />WORKERS COMPENSATION
<br />ANp EM Y/ N
<br />3028347-2016
<br />10/1/2016
<br />10/1/2017
<br />P��r2 I
<br />✓ SIA7U1E E'2 _.�-�--
<br />—
<br />:ANYPRO
<br />PHI EIOR/PFlRTYEfitLXECIITIV-
<br />OFFICER/M.EMBEREXCLUDI.D, I N/AI
<br />E t EACH, p 1,000,000
<br />H, A( CIDENT
<br />(Mandatory in NH)
<br />I
<br />E.L. DISEASE - EA EMPLOYE�5 1,000,000
<br />IDE^CRIPTIONOF
<br />If yes, descnbe Under
<br />OPERATIONSbelaw I
<br />- —
<br />-_--_-_ --�--
<br />(�_
<br />!E.L.DISEASE-POLICY
<br />_E�
<br />LL^dl7 ;5 1rOOO,000'
<br />L
<br />.Pollution Liability C;?=d33�400<1ot)5
<br />11/I/201t
<br />11/1/2017
<br />tleeer,�tA�,:�a,I�: 5,000,000
<br />r"rh P,A'Won c: e„tm: ,e. 510001000
<br />DESCRIPTION OF OPERATIONS t LOCATION / VEHICLES (ACORD 101 Addillanal Remarks Scha(lula, may be attachod if more space is required)
<br />�2e: 'A-1117-036 J.G AGM d"A-2114-111 r AC 1' C' ,r o Santa Ana unlic ,forks, its o seers;, employees, agenrs,
<br />Volunveers and rerre ent�at:veS are r.c_e.Lry nat,!,ed as Addc...ona1 Insured, .'L reatz:rred by wr-Itten contract:, per
<br />endorserre:_t hereto. +ower of Si.1L^rcgatirn 1s nro,r_ded, as required by written contract with the -_..;used as respects
<br />coverage evidenced herein. Coverage cvadenced herain is rrwn•ary and non-contributory, except Auto f - '.ability, vrizicli
<br />primary; it is not non-contributory n at or ly r �pect to ^bodily injury," or "property dila",cage' liab' 1 Ly arising
<br />out of "your wor; ," A sC clay notice shati.be mar lel n the cert ficatH 1,older: t.he address nrov tied he z,
<br />should a described po'_cyls) be c_ancelle,i n_.o_c=, ex,p nation da --e thereof; '-"-,d ,o �r.e for non n;xyrr-.nl of pr_ra um.
<br />.._ ...,,,,.._,m......m s _.-.
<br />REVIEWED BY: EUNICE HE•REDIA (PG I OF )
<br />_
<br />CERTIFICATE HOLDER CANCELLATION'
<br />Holder's Nature of Interest : Certificate Molder
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />City of Santa Ana
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />Executive Director - Public works Agency
<br />AUTHORIZEDR PRESENTATIVE " a
<br />20 Civic Center Plaza NI -21
<br />PO Box 1988
<br />Santa Ana, CA 92702
<br />©1988-2015 ACQRD CORPORATION. All rights reserved.
<br />ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
<br />
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