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IDOSAM-01 CERTIFICATE OF LIABILITY INSURANCE I DATE ( CM D^IYYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on PRODUCER Southern California Insurance Brokerage 3110 E. Guest! Road Suite 500 Ontario, CA 91761 INSURED Vido Samarzich, Inc. 6829 Billings Place Rancho Cucamonga, CA 91701 484-2456 COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOWHAVE BEEN ISSUEDTOTHE INSURED NAMEDABOVE FORTHE POLICYPERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECTTO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE LTR ADDLiSUBR NSD MD POLICY NUMBER POLICY EFF POLICY E%P MMIODMlVV MMIDDIVYYY LIMITS A X COMMERCWLGENERALUABILITY EACH OCCURRENCE S 1,000,000 _ J CLAIMS -MADE X OCCUR 60456974 12/23/2019 12/23/2020 DAMMGES'E. 105,000 X occun0ence S MED EXP An one person) S $,000 __ PERSONAL&ADV INJURY 5 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER �,,. ! GENERAL AGGREGATE 5 2,000,000 _.. POLICY X JECT LOC '_PRODUCTS-COMP/OP AGO 5 2,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident 5 ANY AUTO BODILY INJURY Per oersonl 5 OVINED SCHEDULED _AUTOS ONLY II AUTOpSS BODILY INJURYIPeraccldent 5 AUTOS AUOTOS ONEDY aced BLAMAGE ONLY j IPeOr 5 5 A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE 5 1,000,000 EXCESS UAB CLAIMS -MADE 60455974 12123/2019 12123/2020 AGGREGATE 5 11000,000 DED RETENTIONS 5 B WORKERS COMPENSATION X PER I OTH- ANDEMPLOYERS'LWBILITY YIN STATUTE ER ANY PROPRIETORIPARTNERIEXECUTIVE X 7600020438191 $I22@019 $l22/2020 E.L.EACH ACCIDENT 5 1,000,000 OFFICERIMEMBER EXCLUDED? NIA NH) 1,000,000 (Manda[0ryin F_. L. DISEASE -EA EMPLOYEES It,, dasarihe weer 1,000,000 DESCRIPTION OF OPERATIONS below EL.DISEASE -POLICY LIMIT 5 A Rented/Leased Equip. 60455974 12/2312019 12123/2020 ICORO Limit 100,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES 1 101, Additional Remarks Schedule, may be attached if mare space is required) RE: PROJECT NO. 19-7528; RESIDENTIAL STREET REPAIR PROGRAM. THE CITY OF SANTA ANA, ITS OFFICERS, EMPLOYEES, AGENTS AND REPRESENTATIVES ARE NAMED AS ADDITIONAL INSURED ON THIS POLICY PURSUANT TO WRITTEN CONTRACT, AGREEMENT, OR MEMORANDUM OF UNDERSTANDING. -All (ON -GOING 8 COMP. OPS), PRIMARY WORDING AND W.C. WAIVER ATTACHED. 30-DAY NOC TO FOLLOW. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CITY OF SANTA ANA THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. RISK MANAGEMENT DIVISION 20 CIVIC CENTER PLAZA Santa Ana, CA 92702 AUTHORIZED REPRESENT THE a�A ACORD 25 (2016/03) © 198 5 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered markV6f ACORD