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HomeMy WebLinkAboutWELLDYNE/RXWEST 1C-2016A-2016-104 INSURANCE ON 0L[ CEED UNTL NSURA�CEFXiIRES CLEANCII,.�.,. FrP. vov vle. o-1'S-1 UJ THIRD AMENDMENT TO AGREEMENT THIS THIRD AMENDMENT TO AGREEMENT is entered into this 47o day of May, 2016, by and between WellDyne/RxWest ("Consultant'), and the City of Santa Ana, a charter city and municipal corporation duly organized and existing under the Constitution and laws of the State of California ("City"). RECITALS A. The parties entered into Agreement A-2007-278, dated December 3, 2007, to ensure used medical needles ("sharps") are collected and disposed of in safe and sanitary manner. B. On December 31, 2008, the parties executed a First Amendment to the Agreement No. A-2007-278-01, to extend the term of the agreement. C. On June 30, 2010, the parties executed a Second Amendment to the Agreement No. A-2007-278-02, to extend the compensation and term of the Agreement. C. In accordance with the terms and conditions of the Agreement, the parties desire to amend the compensation and extend the Term of the Agreement. WHEREFORE, in consideration of the covenants contained in the Agreement, and subject to all the terms and conditions of the Agreement, except those amended by the First and Second Amendment, the parties agree as follows: 1. Section 4, COMPENSATION, shall be amended to increase compensation in the amount not to exceed $25,000.00, to pay for the additional services during the extended tern. 2. Section 3, TERM, shall be amended to extend the term of said Agreement period to June 30, 2018. Except as hereinabove modified, the terms and conditions of said Agreement remain unchanged and in full force and effect. IN WYFNESS WHEREOF, the parties bereto have executed this Third Amendment to the Agreement the date and year first above written. ATTEST: c_ MARIA D. HUIZAR Clerk of the Council CITTY O TA ANA DAVID CAV OS City Manager Page 1 of 2 APPROVED AS TO FORM: Carvalho, City Attorney IOSE SANDOVAL, Chief Assistant City FOR APPROVAL: CONSULTANT FR D OUSAVIPOUR, P.E. By: 2cG` Executive Director of Title: P� Cy -- Public Works Agency Page 2 of 2 A4C4[:>R"r CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYVYY) t2/7/20t6 1 5/25/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND 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 a dorsement(s). PRODUCER Lockton Companies 8 t 10 E. Union Avenue Suite 700 Denver CO 80237 CNT OACT NAME: PHONE FAX IC No rzf: AIC No: EMAIL ADDRESS: (303)414-6000 INSURED WeIlDyne RX, Inc. 1405981 500 Eagles LandingDrive Lakeland, FL 33810 INSURERS AFFORDING COVERAGE NAICA INSURER A: Arch Specialty Insurance Company 21199 INSURER B : Trans ortatlon Insurance Company 204.94 IrvsugeR c:CODtlnental Casualty Company 20443 INSURER D: ACE American Insurance Company 22667 INSURER E : INSURER F: C111/7RArOFC nconannTr-n -------"'—"—"'--"' nCVIOIVIV IVU11flot'S: XXXXXXX 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 ADDL SUBR LTq I TYPE OF INSURANCE NSD WVD POLICY NUMBER MOLICYYVY Pot MYI'sp LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X OCCUR N N FLP0052651-03 12/7/20I5 12/7/2016 EACH OCCURRENCE $ 1,000,000 PREMISES Ea occurrence) $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL &ADV INJURY $ 1 000 000 GEN'L AGGREGATE LIMIT APPLIES PER: Poucv n PRO- JECT LOG GENERAL AGGREGATE $ 3 000 000 PRODUCTS COMRADE AGO $$ 3000000 OTHER', - --- $ B AUTOMOBILE X X LIABILITY ANYAUOWNEDO OWNED SCHEDULED AUTOS ONLY _X_ AUTOS HIRED X. NON -OWNED AUTOSONLV AUTOS ONLY N N 5093294681 12/7/2016 2/7/2017 COMBINED SINGLE LIMIT Ea accident $ 100Q000 BODILY INJURY (Par person) $ XX XXXXX BODILY INJURY (Per accident) $ XXXXXXX PROPERTY DAMAGE Per accldenl - $ XXXXXXX $XXXXXXX A X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS MADE N N FLP0052651-03 1 12/7/2015 12/7/2016 EACH OCCURRENCE ,AGGREGATE _$ 3 0�0 Q00 $ 3 000,000 C DEBT RETENTION WORKERS COMPENSATION AND EMPLOYERS' LIABILITY y/N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatorytyes,d in NH) N/ A N 6021940902 '., 6/1/2016 6/l/2017 ORH- X STATUTE I '$ XXXXXXX E.L, EACH ACCIDENT $ 1 00000 0 E.L. DISEASE - EA EMPLOYEE _ .$ 1 000 000 A * Nantler DESCRIPTION DESCRIPTION OF OPERATIONS below Pharmacy Prof. Liability PBM/TPA E&O Liability N N FLP0052651-03 1 12 9 G25673529 0 /7/-U15 J7/2016 12/7/2016 2/7/2017 E.L. DISEASE - POLICY LIMIT $ 1,000,000 $ 1,000,000/$3, $1,000,000/$L,000,000 00,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) *Please see attached list of Named Insureds* rcCTICIn ATM unl not 14148761 City of Santa Ana ATTN: Christy Kindig 20 Civic Center Plaza, M-21 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 ©1988. 015 ACORD CORPOFrATI0M E00 fit AUUISU ZO le5JI 3) The ACORD name and logo are registered marks of ACORD ACORD, CERTIFICATE OF LIABILITY INSURANCE 2/7/2018 DATE(MM/DD/YYYY) 2/16/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND 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 Lockton Companies 8110 E. Union Avenue Suite 700FAII Denver CO 80237 CONT CT NAME: PHONE A/C, No Ext : A/C No): E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC # (303) 414-6000 INSURER A: Arch Specialty Insurance Company 21199 INSURED N/ellDyneRX, LLC. INSURER B : Zurich American Insurance Company 16535 1424829 500 Eagles Landingg Drive Lakeland, FL 33810 INSURER C : Lexington Insurance Company 19437 INSURER D : INSURER E INSURER F : COVERAGES CERTIFICATE NUMBER: 14516082 REVISION NUMBER: XXXXXXX 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 ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ❑OCCUR X N N FLP006017700 2/16/2017 2/7/2018 EACH OCCURRENCE 1,000,000 DAMAGERENTED PREMISESS( Ea occurrence 100,000 MED EXP (Any oneperson) 5,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY❑ JEC ❑ LOC OTHER: GENERAL AGGREGATE $ 3,000,000 PRODUCTS - COMP/OPAGG $ 3,000,000 $ A AUTOMOBILE LIABILITY ANY AUTO AUTOSDONLY SCHEDULED AUTOS ONLY X AUUTOS ONL� N N FLP006017700 2/16/2017 2/7/2018 Ee aaadentSINGLE LIMIT $ 1,000,000 BODILY INJURY (Per person) $ }{}{}{XXXX BODILY INJURY (Per accident $ XXXXXXX X Pear a.,denDAMAGE $ XXXXXXX $XXXXXXX A X UMBRELLA LIAB EXCESS LIAB [IOCCUR CLAIMS -MADE N N FLP006017700 2/16/2017 2/7/2018 EACH OCCURRENCE $ 10,000000 AGGREGATE $ 10,000 000 DED I I RETENTION $ $ xxxxXXx H WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ OFFICER/MEMBER EXCLUDED? N (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A N WC014390900 2/16/2017 2/7/2018 X PER- OER E.L. EACH ACCIDENT $ �000 000 $ E.L. DISEASE - EA EMPLOYEE 1,000,000 E.L. DISEASE - POLICY LIMIT 1,000,000 A C Pharmacy Prof. Liability PBM E&O Liability N N FLP006017700 094274097 2/16/2017 2/7/2017 2/7/2018 2/7/2018 $1,000,000/$3,000,000 Limit. $8M/Retention $250K DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) LICK 1 IFIGA 1 t HULUtK GANULLLA I IUN ° SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLE F E THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 14516082 AUTHORIZED REPRESENTATIVE City of Santa Ana ATTN: Christy Kindig 20 Civic Center Plaza, M-21 Santa Ana, CA 92701 ff j ACORD 25 (2016103) ©198812015 ACORD CORPO ATION. All riahts reserved -0 The ACORD name and logo are registered marks of ACORD AC"R"' CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 11111 2/16/2018 1 2/9/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND 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 Lockton Companies 8110 E. Union Avenue Suite 700 Denver CO 80237 NAME; T PH NE FAX A/C No Ext : A/C No): E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC # (303) 414-6000 INSURER A : Arch Specialty Insurance Company 21 199 INSURED WellDyneRX, LLC. 1424829 500 Eagles Landing Drive Lakeland, FL 33810 INSURER B : Zurich American Insurance Company 16535 INSURER C : Lexington Insurance Company 19437 INSURER D : Ll0 CIS Of London INSURER E: Berkley Insurance Company 32603 t " t INSURER F COVERAGES CERTIFICATE NUMBER: 14516082 REVISION NLIMRER- XXXXXXX 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 ADDL. INSD SUBR WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY N N FLP006017701 2/16/2019 2/16/2019 EACH OCCURRENCE 5 1,000,000 CLAIMS -MADE OCCUR ]{ DAMAGE TO RENTED PREMISES Ea occurrence 100,000 IVIED EXP (Any oneperson) 5,000 PERSONAL & ADV INJURY $ 1 000 000 GEN'L AGGREGATE LIMIT APPLIES PER. POLICY❑ JECT ❑ LOC GENERAL AGGREGATE $ 3,000,000 PRODUCTS -COMP/OP AGG $ 3,000,000 $ OTHER: • AUTOMOBILE LIABILITY N N FLP006017701 2/16/2018 2/16/2019 COeBINEDtSINGLE LIMIT $ 1,000,000 BODILY INJURY (Per person) $ xxxxxxx ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident $ XXXXXXX AUTOS ONLY x AUUTOS ONLYY x Peo, :c d nDAMAGE $ XXXXXXX $ xxxxxxx A ]{ UMBRELLA LAB X 'OCCUR N N FLP006017701 2/16/2018 2/16/2019 EACH OCCURRENCE $ 10,000,000 AGGREGATE $ 10,000,000 EXCESS LIAB CLAIMS -MADE DED I I RETENTION $ $ xxxxxxx B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/ N N WC014390901 2/16/2018 2/7/2019 X STATUTE o R E.L. EACH ACCIDENT $ I OOO OOO ANYOFFICER MEMBOER EXCLUDED? ECUTIVE FN (Mandatory in NH) It yes, describe under DESCRIPTION OF OPERATIONS below N / A E.L. DISEASE - EA EMPLOYEE _JjJ]000,000 E.L. DISEASE - POLICY LIMIT 1, 1,000,000 A C Phannacvprof ljab PBM E&O Liab. N N FLP006017701 012110742 2/16/2018 2/16/2018 2/16/2019 2/16/2019 $IM/$3M Limit: $8M/Ret $250K D E Cyber Crime MPL184736417 BCCR4500242320 2/16/2017 10/21 /2016 2/16/2018 2/16/2018 Limit: $5M Ea. Claim/$5M Agg Limit: $2M per Oce. DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 14516082 AUTHORIZED REPRESENTATIVE City of Santa Ana ATTN: Christy Kindig 20 Civic Center Plaza, M-21 Santa Ana, CA 92701 9 C % &rili ram( ACORD 25 (2016/03) ©1988 2015 ACORD CORPOWATION. All rights reserved a0 The ACORD name and logo are registered marks of ACORD Digitally signed Ac"Mor CERTIFICATE OF LIABILA W E DATE (MMIDDIYYYY) �.,.,,� /l4 3 n 11Q2022 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS WRIGHTS UPON TF c -FxRTIFICATE H LDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGF AF,Qex*tQPOLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A ZITRACT BETWEEN THE ' UING Ii:`zURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy es) A DI D provisions c: be en orsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may rer,uire an en(yeP q,,:4tten�tt7► �J 7.lJo.`} �J lJ D this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).CONTACT PRODUCER Lockton Companies _ NAME, PHONE FAX A/C No): 8110 E Union Avenue Suite 100 Denver CO 80237 E-MAIL ADDRESS: (303) 414-6000 INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Arch Specialty Insurance Company 21199 INSURED WellDyneRX, LLC 1477414 500 Eagles Landing Drive INSURER B : Zurich American Insurance Company 16535 INSURER C : ACE American Insurance Company 22667 INSURER D : Berkley Insurance Company 32603 Lakeland, FL 33810 INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: 14516082 REVISION NUMBER: XXXxxS x 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 ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY N N FLP006017705 2/16/2022 2/16/2023 EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE 1XI OCCUR DAMAGE T PREM SESOEa occurrDence $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 POLICY n PRO - POLICY F-1 LOC PRODUCTS - COMP/OP AGG $ 3,000,000 $ OTHER: A AUTOMOBILE LIABILITY N N FLP006017705 2/16/2022 2/16/2023 COMBINED SINGLE LIMIT Ea accident $ 1,000,000 BODILY INJURY (Per person) $ XXX)CS XX ANY AUTO OWNED SCHEDULED AUTOS ONLYNAUTOS BODILY INJURY (Per accident) $ XXX�CSCSCS� Xr PROPERTY DAMAGE Per accident $XXXXXXX HIRED NON -OWNED AUTOS ONLYAUTOS ONLY $ XXXyCS xx A X UMBRELLA LIAB X OCCUR N N FLP006017705 2/16/2022 2/16/2023 EACH OCCURRENCE $ 10,000,000 A EXCESS LIAB CLAIMS -MADE Prof. Liab. RetroDate: 2/16/20 X AGGREGATE $ 10,000,000 DED RETENTION $ $ XXXXX� B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) N / A N WC014390905 2/16/2022 2/16/2023 EROTH- X STATUTE 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 Pharmacy Prof. Liab. N 2/16/2022 2/16/2023 $1M/$3M Retro Date: 2/16/2020 C PBM E&O Liab. =FLPOR046017705 2508130002 2/16/2022 2/16/2023 Limit: $3M/Ret $250K D Crime 500242325 2/16/2022 2/16/2023 Limit: $2M per Occ. DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) Per Agreement Master Agreement A-2007-278 and current agreement A-20180-131-01 with the City of Santa Ana, Proof of Worlcers' Compensation Coverage. 14516082 City of Santa Ana Risk Management Division 20 Civic Center Plaza Santa Ana CA 92701 ACORD 25 (2016103) 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,— Risk M8118gement DMskrn +� �m REVIEWED & APPROVED BY: @ 1 s88-2o ACo The ACORD name and logo are registered marks of ACORD r Risk Management Specialist off IN Miscellaneous Attachment: M577149 Master ID: 1477414, Certificate ID: 14516082 Excess Liability Schedule Carrier Policy Number Limit Lloyd's of London MCFAL1000459 $25,000,000 Lloyd's of London B0180PC2209645 $30,000,000 m Risk Management DlMsian REVIEWED & APPROVED BY: r Risk Management Specialist