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ACoRD0 CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 12/28/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Customer Service Department NAME: Target Insurance Services ACNE Ext : (800) 450-8013 FAX : (866) 227-3052 6630 Flanders Drive E-MAIL Certificates@premieragencyservices.com ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # San Diego CA 92121 INSURERA: Western World Insurance Co 13196 INSURED INSURER B : United Financial Casualty CO 11770 Forness Construction Inc INSURER C : State Compensation Ins Fund of CA 35076 1141 Rosemary Circle INSURER D : INSURER E : Corona CA 92879 INSURER F : COVERAGES CERTIFICATE NUMBER: PP/XS/BA/WC 18-19 REVISION NUMBER! THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE AUULbU INSD WVD POLICY NUMBER POLICY EFF MMIDDIYYYY POLICY EXP MMIDDIYYYY LIMITS X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ❑X OCCUR EACH OCCURRENCE $ 1,000,000 DAMAGETORENTE07— PREMISES Ea occurrence $ 50,000 MED EXP (Any one person) $ 10,000 BADVINJURY $ 1,000,000 A Y Y EVP100107700 05/03/2018 05/03/2019 GEN'L AGGREGATE LIMIT APPLIES PER: -PERSONAL GENERAL AGGREGATE $ 2,000,000 X POLICY ❑ PRO- LOC PRODUCTS-COMPIOPAGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,000 ANYAUTO BODILY INJURY (Per person) $ B IX OWNED SCHEDULED AUTOS ONLY AUTOS 01931135-6 11/06/2018 11/06/2019 BODILY INJURY (Per accident) $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTYDAMAGE Per accident $ Uninsured/Underinsured $ 1,000,000 UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 A X E ICLAIMS-MADE EVX100107800 05/03/2018 05/03/2019 AGGREGATE $ 1,000,000 DED RETENTION $ $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) N /A 9149967-2017 12/3012018 12/30/2019 X SPER H TATUTE ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 A Pollution Liability Bailees EVP100107700 05/03/2018 05/03/2019 Aggregate $2,000,000 $250,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The City of Santa Ana, it's officers, employees, agents and representatives are named as Additional Insured; Primary Non-Contibutory Wording applies, per the attached Endorsement(s). Certificate Holder Reference: On -Call Agreements A-2017-220 `Additional Insured status is subject to all policy terms, exclusions and conditions' REVIEWED BY: EUNICE HEREDIA (PG (OF ) The City of Santa Ana Public Works Agency 20 Civic Center Plaza, M-36 Santa Ana CA 92701 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD