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,�,,;"CERTIFICATE OF LIABILITY
<br />;.it INSURANCE
<br />DATE. (MMIDD/YYYY)
<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 SIP Insurance Services NAAE FACT SIP Insurance Services..
<br />..- .. FAX
<br />750 The Coy Drove South, Ste 450 PHONE
<br />A s) ._. _._.. 626-214-7902 A e Nc1:.�.....
<br />Change, CA 92t38 E-MAIL
<br />INSURED
<br />Backflow Apparatus & Valve Company
<br />DBA BAVN
<br />20435 S. Susana Road
<br />Long Beach CA 99810
<br />A:
<br />B:
<br />COVERAGE ICFRTIFICATF N1llMRr-R- rAQA1r90 KIlrMnnt:0.
<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 THUS
<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 ..,..._.._...._.,.... ADDL SUBR _....... .. _...
<br />POLICY EFF POLICY EXP .,-.._-___.. _.-...
<br />LTR TYPE OF INSURANCE .......
<br />POLICY NUMBER IMMIDDrMa MMIDDFYYYY LIMITS
<br />A
<br />. ✓.,
<br />COMMERCIAL GENERAL LIABILITY
<br />ryf
<br />630-8J664090
<br />1.0/31/2019
<br />10131/2020
<br />EACH OCCURRENCE
<br />$"Ii,.000,000__.
<br />��
<br />CLAIMS-MADE.y l OCCUR
<br />❑p,.MAGE TCS RENTEC%.....
<br />PREMISES Eaoccurrence8
<br />$300,,000
<br />.....
<br />MED EXP (Any one person)
<br />$ 5,000 -
<br />_.
<br />PERSONAL & ADV INJURY
<br />$ 1,000,000
<br />.mm--..._.
<br />AGGREGATE LIMIT APPLIES PER:
<br />GENT
<br />GENERAL AGGREGATE
<br />s 2,000,..000
<br />❑,......
<br />0
<br />_
<br />POLICY JECT LOC
<br />PRODUCTS - COMP/OP AGO
<br />$2,000,000
<br />OTHER:
<br />$
<br />A
<br />AUTOMOBILE
<br />LIABILITY
<br />BA-7N173419
<br />10131/2019,
<br />10/31/2020
<br />COMBINED tSINGLE LIMIT^
<br />$1,000„000
<br />ANY AUTO
<br />BODILY INJURY (Per person)
<br />$
<br />......
<br />OWNEAUTOS ONLY AUTOS SCHEDULED
<br />AUTOS
<br />BODILY INJURY (Per accident)
<br />$
<br />✓,,,,,,,,
<br />HIRED I--.NION-OWNED
<br />✓
<br />PR6PERTY -DAMAGE
<br />.._�- .......
<br />$
<br />AUTOS ONLY _ AUTOS ONLY
<br />Per accidertCS
<br />A
<br />UMBRELLA LIAB
<br />N
<br />OCCUR
<br />CUP-9J209005
<br />10131/2019
<br />10/31/2020
<br />EACH OCCURRENCE
<br />$5,000,000
<br />AGGREGATE
<br />$5,000,000
<br />EXCESS LIAR
<br />CLAIMS -MAIL
<br />DED ''�. ✓ RETENTION$0
<br />... ..�..
<br />$
<br />A
<br />WORKERS COMPENSATION
<br />UBOL941578
<br />8/27/2019
<br />8/27/2020
<br />✓ PE�TUTE ORH-
<br />AND EMPLOYERS" LIABILITY Y 1 N
<br />_.__-.-.... - ..
<br />- ........�..
<br />ANYPROPRIETOR/PARTNEWEXECUTIVE
<br />E.L.EACHACCIDP;NT
<br />$1,000,000
<br />OFFICERWEM®EREXCLUDED?
<br />NIA
<br />..
<br />(Mandatory in NH)
<br />E.L. DISEASE EA (EMPLOYEE
<br />$1 000
<br />----�°Q-.
<br />If yes, describe under
<br />E.L. DISEASE - POLICY LIMIT
<br />$ 1,000,000
<br />DESCRIPTION OF OPERATIONS below
<br />DESCRIPTION. OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule may be attached if more space ns required)
<br />City of Santa Ana and its officers, employees, agents, volunteers and representatives are named as additional insureds in respects to the general
<br />liability policy only per the attached forms. Primary/non-contributory is included in the general liability policy only per the attached form.
<br />30 days notice of cancellation applies to the certholder in regards to the general liability policy only.
<br />ENSarl�r.;f�rr�:[r��•I�cIll€�r��Illlr��u�I�I°�rl�u�..
<br />Risk ANAgf-mFtgr IVOIC)N
<br />City of Santa Ana
<br />SHOULD ANY QF THE ABOVE DESCRIBED
<br />POLICIES BE CANCELLED BEFORE
<br />..
<br />Risk (Management DIVISIon
<br />20 Civic Center Plaza 4th FL
<br />w
<br />THE EXPIRATION( DATE THEREOF,
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />NOTICE WILL BE DELIVERED IN
<br />Santa Ana CA 92702
<br />AUTHORIZED REPRESENTATIVE
<br />_t= r
<br />Gary Champlin
<br />CO 1968-2015 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
<br />s4841562 119-at, GL, AIAQ, thlb, wr I Kahtiri Datol 1 3/10/2e20 xro�ae:ie AM (PDT) I PaL+ a of 10
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