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Francine R. .d by r,�..... P.
<br />i,m
<br />Villareal
<br />acoRO CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY)
<br />09/28/2020
<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. Astatement on
<br />this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
<br />PRODUCER
<br />CONTACT Jennie Garcia
<br />NAME:
<br />The Empire Company
<br />PHONE (714) 836-9945 FAX (714) 836-9946
<br />E IC. No Ext . AIC No
<br />550 North Park Center Drive
<br />ADDRESS: Igarcia@empire-co.com
<br />Suite 205
<br />INSURER(S)AFFOROING COVERAGE
<br />NAICN
<br />Santa Ana CA 92705
<br />INSURERA: Ohio Security Insurance Company
<br />24082
<br />INSURED
<br />INSURER B. American Fire and Casualty Insurance Company
<br />24066
<br />Transportation Studies Inc
<br />INSURERC, United States Liability Insurance Company
<br />25895
<br />264D Walnut Ave Ste L
<br />INSURER D'.
<br />INSURER E
<br />Tustin CA 92780
<br />INSURER F:
<br />COVERAGES CtFICATE NUMBER: 2u-zi Master REVISION NUMBER:
<br />In lb Is IU GEKI IF I HAI I HE 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 CONTRACTOR OTHER DOCUMENT VVITH RESPECTTO WHICH THIS
<br />CERTIFICATE MAYBE 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 />9999
<br />WVD
<br />POLICY NUMBER
<br />POLICY EFF
<br />MMIDDIYYYY
<br />POLICY EXP
<br />MM/DD/1EXP
<br />LIMITS
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />CLAIMS -MADE X OCCUR
<br />EACH OCCURRENCE
<br />$ 1,000,000
<br />DAMAGE RENTE
<br />PREMISES Ea occurrence
<br />$ 5001000
<br />MEDEXP(Anyoneperson)
<br />$ 16,000
<br />A
<br />BK859050934
<br />10101/2020
<br />10/01/2021
<br />PERSONAL&ADV INJURY
<br />$ 1,000,000
<br />GEN'LAGGREGATE
<br />X
<br />LIMITAPPLIES PER:
<br />POLICY D JECT PRO
<br />❑ Loc
<br />GENERAL AGGREGATE
<br />$ 2,000,000
<br />PRODUCTS-COMPIOP AGG
<br />$ 2,000,000
<br />$
<br />OTHER-
<br />AUTOMOBILE
<br />LIABILITY
<br />ANYAUTO
<br />COMBINED SINGLE LIMIT
<br />Ea accident
<br />$ 1000,000
<br />X
<br />BODILY INJURY (Per person)
<br />$
<br />A
<br />OWNED SCHEDULED
<br />AUTOS ONLY AUTOS
<br />HIRED NON -OWNED
<br />AUTOS ONLY AUTOS ONLY
<br />BAS59050934
<br />10/0112020
<br />10101/2021
<br />BODILY INJURY (Per accident)
<br />$
<br />PROPERTY DAMAGE
<br />Per accident)$
<br />Uninsured motorist
<br />s 1,000.000
<br />B
<br />X
<br />UMBRELLA UAB
<br />EXCESS LIAB
<br />X
<br />OCCUR
<br />CLAIMS -MADE
<br />USA59050934
<br />10101/2020
<br />10101/2021
<br />-- W6 _` �• •a•—
<br />EACH OCCURRENCE
<br />$ 1,000,000
<br />AGGREGATE
<br />$ 1,000,000
<br />OEO I X RETENTION $ 10,000
<br />$
<br />A
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY YIN
<br />ANY PROPRIETOR/PARTNER/EXECUTIVE
<br />OFFICERIMEMSER EXCLUDED? F1
<br />NIA
<br />XWS59050934
<br />10/01/2020
<br />10/0112021
<br />X PER STATUTE EORH
<br />EL EACH ACCIDENT
<br />$ 1,000,000
<br />EL. DISEASE -EA EMPLOYEE
<br />$ 1,000,000
<br />(Mandatory in NH)
<br />If yes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />EL. DISEASE -POLICY LIMIT
<br />$ 1,000,000
<br />Errors &Omissions
<br />Each Claim
<br />$1,000.000
<br />C
<br />SP10227431
<br />10/01/2020
<br />10/01/2021
<br />Aggregate
<br />$2,000.000
<br />DESCRIPTION OF OPERATIONS I LOCATIONS i VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space Is required)
<br />Re: Agreement to Provide Traffic Counting Services on an On -Call Basis
<br />The City of Santa Ana, its officers, employees, agents, volunteers and representatives are named as additional insureds with primary/non-contributory
<br />wording in respect to the general liabilty coverage per forms CG88100413 attached as required by written contract.
<br />City of Santa Ana, Risk Management Division,
<br />4th Floor
<br />20 Civic Center Plaza
<br />Santa Ana
<br />ACORD 25 (2016103)
<br />CA 92702
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />AUTHORIZED REPRESENTATIVE
<br />@ 1988-2015 ACORD
<br />The ACORD name and logo are registered marks of ACORD
<br />RI6i4181agariesd Di$fsion
<br />REVIEWED & APPROVED BY.'
<br />�llii:llJCL' F4.s-w.�.+�a R. v:.Q!I
<br />Risk Management Analyst
<br />
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