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Tori Pierson Digitally signed byTai Pierson
<br />Date: 2021.08.25 10.50.13-07'00'
<br />, coRa® CERTIFICATE OF LIABILITY INSURANCE
<br />DATE DIY
<br />08/138/13/202121
<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 certticate holder Is an ADOtTtONAL INSURED, the poticy(tes] must be endorsed. If SUBROGATION IS WAIVED, subject to
<br />the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
<br />certificate holder In lieu of such endorsement4s).
<br />PRODUCER
<br />CONTACT
<br />Recia Shelton
<br />Van Beurden Ins, Serv, Inc. - Kingsburg
<br />PHONE FAX
<br />E {559) 897-2975 ;AIC No} (S5g) 897-4070
<br />PO Sax 67
<br />E-M
<br />Kingsburg CA 93631
<br />DRESSA€L
<br />: A° — - —'
<br />INSURERS AFFORDING COVERAGE NAIC N
<br />y
<br />INSURER A: NY Marine & General Ins Co 16608
<br />INSURED
<br />INSURER6:Falls Lake Fire & Casualty --Co
<br />15884
<br />Peat Options, Inc.
<br />INSURERC:StaY3tone National Ina Co.
<br />25496
<br />INSURER D:
<br />P,O. Box 5827
<br />INSURERE:
<br />Orange CA 92863
<br />w
<br />INSURER F :
<br />COVERAGES CERTIFICATE NUMRER: Cert ID 40476 RFVISION NI1M8FR-
<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 />A DL
<br />S
<br />USR
<br />O
<br />I POLICY NUMBER
<br />POLICY EFF
<br />MMIDDIYYYY
<br />POLICY EXP
<br />MMIDD/YYYY
<br />LIMITS
<br />GENERAL LIABILITY
<br />EACH OCCURRENCE
<br />$ 1,000,000
<br />PREMISES Ea occurrencel
<br />$ 100,000
<br />A
<br />X COMMERCIAl, GENERAL LIAO1ITY
<br />PK202100009523
<br />01/22/2021
<br />01/22/2022
<br />CLAWS -MADE L X ' OCCUR
<br />ME EXP (Any one person)
<br />$ 5, 0 00
<br />PERSONAL & ADV INJURY
<br />$ I,000,000
<br />X SI/PIT Dad: 1,000
<br />X
<br />^Pest./Harb.End.
<br />GENERAL AGGREGATE
<br />$ 2,000,000
<br />GEN'L AGGREGATE LIMIT APPLIES PER:
<br />PRODUCTS - COMPIOP AGG
<br />$ 2, 000, 000
<br />X POLICY r PRD LOC
<br />$
<br />AUTOMOBILE
<br />LIABILITY
<br />COMBINERSINGLE IMIT
<br />Ea accident
<br />SOMLY INJURY (Per person}
<br />$
<br />ANY AUTO
<br />ALL OWNED SCHEDULED
<br />AUTOS AUTOS
<br />NON -OWNED
<br />HIRED AUTOS AUTOS
<br />BODILY INJURY (Per accident}
<br />$
<br />PROPERTY DAMAGE
<br />Per acciden-tL_
<br />$
<br />C
<br />g
<br />UMBRELLALIAB
<br />R
<br />OCCUR
<br />75914I217ALI
<br />01/22/2021
<br />01/22/2022
<br />EACH OCCURRENCE
<br />$ 3,000,000
<br />AGGREGATE
<br />$ 3 , DDD I D00
<br />EXCESS LIAS
<br />CLAAiS-MkUS
<br />RED I I RETENTION$
<br />Co m feted a
<br />$ 3,000,000
<br />8
<br />WORKERS COMPENSATION YIN
<br />AND EMPLOYERS' LIABILITY
<br />ANY PRO PRIETORIPARTNERIEXECUTIVE [7
<br />OFFICERIMEMBER EXCLUDED?
<br />(Mandatary In NH)
<br />NIA
<br />FLA00295004
<br />12/29/2020
<br />12/29/202
<br />X IORYLIMIU WO STATIC
<br />OTH-
<br />E.L. EACH ACCIDENT
<br />$ 11000,000
<br />E.L. DISEASE- EA EMP1_OYE9
<br />$ 1,000,000
<br />Ir yyees, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />E.L. DISEASE - POLICY LIMIT
<br />I $ 1 ■ 000, 000
<br />A
<br />Limited Pollution Endt.
<br />PX202100009523
<br />01/22/2021
<br />01/22/2022
<br />$1,000 gI/PD Per $ 1,000,000
<br />Occurence(Occ.Form)
<br />A
<br />Transit: Pollution Endt.
<br />PK202100009523
<br />01/22/202101/22/2022
<br />$1,000 131/PD Per $ 11000,000
<br />Occurence(Occ.Form)
<br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
<br />The City of Santa Ana, Risk Management, it's officers, employees, agents, representatives, and
<br />volunteers are named as additional insured as respect to Ganaral Liability per the attached
<br />form(s)only when required by written contract.
<br />*WC Waiver of Subrogation applies and is attached.
<br />Thirty(30)Days Cancellation Notice applies. Ten(10)Days Cancellation if cancelled for nonpayment.
<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 />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />City of Santa. Ana
<br />Risk Management Division
<br />20 Civic Center Plaza AUTHORIZED REPRESENTATIVE
<br />/.�■1� ' Ruk l�iwgenrnt c iYns�on
<br />Santa Ana CA 92701 ✓ +�.�'� (I ■I';_ 1` �E�& APPROVED 9
<br />@ 1988.2010 ACORD C I I y Risk ManagemensOmral wee
<br />ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD
<br />
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