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DATE (MMIDD/YYYY)
<br />��oKoQa CERTIFICATE OF LIABILITY INSURANCE
<br />6/19/2019
<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 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 CONTACT
<br />NAME: Elizabeth Nicholson
<br />Arthur J. Gallagher Risk Management Services, Inc. PHONE rAX
<br />4200 Corporate Drive Ste 160 N. Ext). _ • 515-457-8964
<br />E-?._6 Elizabeth Nicholson a.eom
<br />West Des Moines IA 50266 ARgRl�53'e;_
<br />INSURED
<br />Elliott Auto Supply Co., Inc. Factory Motor Parts
<br />1380 Corporate Center Curve, Suite 200
<br />Eagan, MN 55121
<br />rnVFRAnPA
<br />rFRTIFIrATF NI IMRFR• RQR'2nQF7Q
<br />INSURERS AFFORDING COVERAGE NAIC#
<br />INSURER A: Employers Mutual Casualty Company 21415
<br />INSURER B : EMCASCO Insurance Company 21407
<br />INSURER C :
<br />INSURER D :
<br />INSURER E :
<br />INSURER F :
<br />Pr-VIRION NIIMRFR-
<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
<br />LTR
<br />TYPE OF INSURANCE
<br />POLICY ER
<br />POLICY EFF
<br />POLICY EXP
<br />LIMITS
<br />A
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />Y
<br />Y
<br />2D39543
<br />11/15/2018
<br />11/15/2019
<br />EACHOCCURRENCE
<br />$1,000,000
<br />CLAIMS -MADE � OCCUR
<br />PA TORE TE
<br />r -Da a
<br />$ 1,000,000
<br />MED EXP (Any one arson
<br />$ 5.000
<br />PERSONAL 8 ADV INJURY
<br />$ 1,000.000
<br />GEN'LAGGREGATELIMIT APPLIES PER:
<br />GENERAL AGGREGATE
<br />$2,000.000
<br />PRO E LOC
<br />POLICY I JECT RO-
<br />PRODUCTS - COMP/OP AGG
<br />$ 2,000,000
<br />Property Damange
<br />$ 1,000,000
<br />.C:THER:
<br />A
<br />AUTOMOBILE LIABILITY
<br />Y
<br />2E39543
<br />11/15/2018
<br />11/15/2019
<br />COMB
<br />,( a accidentINEDSiNGLELIMIT
<br />$1,000,000
<br />BODILY INJURY (Per person)
<br />$
<br />X ANY AUTO
<br />OWNED SCHEDULED
<br />AUTOS ONLY AUTOS
<br />BODILY INJURY (Per accident)
<br />_
<br />$
<br />$
<br />„X HIRED X NON -OWNED
<br />AUTOS ONLY AUTOS ONLY
<br />PROPERTYDAMAGE^
<br />r accident
<br />,
<br />Ded Comp/Collision
<br />$1,000
<br />A
<br />X
<br />UMBRELLALIAB
<br />X
<br />OCCUR
<br />2J39543
<br />11/15/2018
<br />11/15/2019
<br />EACH OCCURRENCE
<br />$3,000,000
<br />AGGREGATE
<br />$ 3,000,000
<br />EXCESS LIAR
<br />CLAIMS -MADE
<br />DED I X I RETENTION $
<br />$
<br />B
<br />A
<br />A
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY y�N
<br />ANYPROPRIETOR/PARTNER/EXECUTIVE rNJ
<br />OFFICER/MEMBER EXCLU E
<br />(Mandatory in NH)
<br />N I A
<br />2N39543
<br />2P39543
<br />21V39543
<br />11/15/2018
<br />11/15/2018
<br />11/15/2018
<br />11/15/2019
<br />11I15I2019
<br />11/15/2019
<br />X MUTE ER
<br />SfatutD
<br />E.L. EACH ACCIDENT
<br />$ 1,000,000
<br />E.L. DISEASE - EA EMPLOYEE
<br />$ 1,000,000
<br />F l- DISEASE - POLICY LIMIT
<br />$ 1,000,000
<br />If yes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />A
<br />GARAGE LIABILITY
<br />2E39543
<br />11/15/2018
<br />11/15/2019
<br />Auto Only- Ea Acc
<br />Other Than - Ea Acc
<br />$500,000
<br />$1,000,000
<br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
<br />Elliott Auto Supply Co., Inc. inclusive of Factory Motor Parts.
<br />RE: Project #14-6809 / Arterial Street Slurry Seal 2013-2014.
<br />The City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California 92702; Its officers, employees, agents and volunteers are included as Additional Insured
<br />under the General Liability policy per form CG7184 (10/13) and auto (lability policy per form CA7270 (03/07) as per written contract requirement pursuant to and
<br />subject to the policy's terms, definitions, conditions, and exclusion. The insurance provided In the General Llabiilty policy Is Primary and Non -Contributory and
<br />any other insurance shall be excess only, and not contributing per form CG7184 (10/13) as per written contract requirement pursuant to and subject to the
<br />insureds General Liability form
<br />policy's terms, definitions, condtolons, and exclusion. Waiver of Subrogation applies to the Additional as respects to the per
<br />CG7555 (4113), pursuant to and subject to the policy's terms when required In a written contract or agreement per form
<br />rFRTIFIr ATF writ nFR I i A r.ANrFI 1 ATIf7N
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />R
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />City of Santa Ana
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />Risk Management Divisi
<br />AUTHORIZED REPRESENTATIVE
<br />20 Civic Center Plaza
<br />Santa Ana CA 92702 Q'Ift Man da entt 1V 6IOt1
<br />'AA
<br />I/rf,%04,
<br />r -0 1
<br />© 1988-2015 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
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