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<br />Tori Pierson Dattea2102 05.03b15:49:53-0700'
<br />ACCORD® CERTIFICATE OF LIABILITY INSURANCE
<br />`l
<br />DATE(MM/DD/YYYY)
<br />1 5/2/2022
<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
<br />RBN Insurance Services
<br />303 E Wacker Dr Ste 650
<br />Chicago IL 60601
<br />CONTACT
<br />NAME: Symone White
<br />PHONE FAX
<br />A/C No Ext : 312-856-9400 A/C, No : 312-856-9425
<br />ADDE-MRESS: swhite@rbninsurance.com
<br />INSURER(S) AFFORDING COVERAGE
<br />NAIC #
<br />wsURERA: Hartford Fire Insurance Co.
<br />19682
<br />INSURED SAFELLC-01
<br />Interwest Consulting Group
<br />P.O. Box 18330
<br />INSURERB: Hartford Casualty Insurance Co
<br />29424
<br />INsuRERc: Great American E&S Ins. Co.
<br />37532
<br />INSURERD: Bridgeway Insurance Company
<br />12489
<br />Boulder CO 80308
<br />INSURER E: Navigators Specialty Ins. Co.
<br />36056
<br />INSURERF: Hartford Insurance Group
<br />COVERAGES CERTIFICATE NUMBER:207230275 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 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 />ADDL
<br />INSD
<br />SUBR
<br />WVD
<br />POLICYNUMBER
<br />POLICY EFF
<br />MM/DD
<br />POLICY EXP
<br />MM/DD
<br />LIMITS
<br />A
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />Y
<br />Y
<br />83UENZV3951
<br />10/3/2021
<br />10/3/2022
<br />EACH OCCURRENCE
<br />$ 1,000,000
<br />CLAIMS -MADE OCCUR
<br />DAMAGE TO RENTED
<br />PREMISES Ea occurrence
<br />$ 1,000,000
<br />MED EXP (Any one person)
<br />$ 10,000
<br />PERSONAL &ADV INJURY
<br />$ 1,000,000
<br />GEN'L
<br />AGGREGATE LIMIT APPLIES PER:
<br />GENERAL AGGREGATE
<br />$ 2,000,000
<br />POLICY ❑PRO ❑
<br />JECT LOC
<br />X
<br />PRODUCTS - COMP/OP AGG
<br />$ 2,000,000
<br />$
<br />OTHER:
<br />B
<br />AUTOMOBILE
<br />LIABILITY
<br />Y
<br />Y
<br />83UENPY9100
<br />10/3/2021
<br />10/3/2022
<br />COMBINED SINGLE LIMIT
<br />Ea accident
<br />$1,000,000
<br />X
<br />BODILY INJURY (Per person)
<br />$
<br />ANY AUTO
<br />OWNED SCHEDULED
<br />AUTOS ONLY AUTOS
<br />BODILY INJURY (Per accident)
<br />$
<br />X
<br />PROPERTY DAMAGE
<br />Per accident
<br />$
<br />HIRED X NON -OWNED
<br />AUTOS ONLY AUTOS ONLY
<br />E
<br />UMBRELLALIAB
<br />X
<br />OCCUR
<br />CH21EXC885600IC
<br />10/3/2021
<br />10/3/2022
<br />EACH OCCURRENCE
<br />$5,000,000
<br />X
<br />AGGREGATE
<br />$ 5,000,000
<br />EXCESS LAB
<br />CLAIMS -MADE
<br />DED X RETENTION $ n
<br />$
<br />F
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY Y / N
<br />Y
<br />83WECE0623
<br />5/12/2022
<br />5/12/2023
<br />X PER OTH-
<br />STATUTE ER
<br />ANYPROPRIETOR/PARTNER/EXECUTIVE
<br />E.L. EACH ACCIDENT
<br />$ 1,000,000
<br />OFFICER/MEMBER EXCLUDED? F
<br />N/A
<br />E.L. DISEASE - EA EMPLOYEE
<br />$ 1,000,000
<br />(Mandatory in NH)
<br />If yes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />E.L. DISEASE - POLICY LIMIT
<br />$ 1,000,000
<br />C
<br />Professional Liability
<br />TER 2861558
<br />10/3/2021
<br />10/3/2022
<br />Each Claim/Aggregate
<br />10,000,000
<br />D
<br />Excess Liab (2nd) Layer
<br />8E-A7-XL-0002079-00
<br />10/3/2021
<br />10/3/2022
<br />Each Occ/Aggregate
<br />5,000,000
<br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required)
<br />The City of Santa Ana, its officers, employees, agents and representatives are Additional Insured on a primary and non-contributory basis as respects the
<br />General Liability and Auto Liability as required by written contract. A Waiver of Subrogation applies in favor of the Additional Insured as respects General
<br />Liability, Auto Liability, and Workers Compensation as required by written contract. 30 Days notice of cancellation applies. 10 days notice of cancellation for
<br />non-payment of premium applies.
<br />CERTIFICATE HOLDER CANCELLATION
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />City of Santa Ana ACCORDANCE WITH THE POLICY PROVISIONS.
<br />Risk Management Division
<br />20 Civic Center Plaza AUTHORIZED REPRESENTATIVE
<br />Santa Ana CA 92702 � rREoe&m & APPRavED Br.
<br />'%,t p a x
<br />@ 1988-2015 ACORD C(
<br />ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
<br />
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