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<br />5,000
<br />100,000
<br />NAIC #
<br />1,000,0001,000,0002,000,0002,000,0001,000,0001,000,0001,000,0001,000,000
<br />10,000,00010,000,000
<br />KSHIPPEY
<br />351812028125674
<br />10/23/2020
<br />DATE (MM/DD/YYYY)
<br />$$$$$$$$$$$
<br />(949) 891-0407
<br />LIMITS
<br />OTH-
<br />FAX(A/C, No):
<br />PERSTATUTEER
<br />X
<br />EACH OCCURRENCE$DAMAGE TO RENTEDPREMISES (Ea occurrence)MED EXP (Any one person)$PERSONAL & ADV INJURY$GENERAL AGGREGATE$PRODUCTS - COMP/OP AGGCOMBINED SINGLE LIMIT(Ea accident)BODILY
<br /> INJURY (Per person)$BODILY INJURY (Per accident)$PROPERTY DAMAGE(Per accident)EACH OCCURRENCEAGGREGATEE.L. EACH ACCIDENTE.L. DISEASE - EA EMPLOYEE$E.L. DISEASE - POLICY LIMIT
<br />REVISION NUMBER:
<br />TEROBERT-0
<br />INSURER(S) AFFORDING COVERAGE
<br />© 1988-2015 ACORD CORPORATION. All rights reserved.
<br />(949) 623-3980
<br />Executive Risk IndemnityFederal Insurance Company Travelers Property Casualty Company of America
<br />9/1/20209/1/20219/1/20209/1/20219/1/20209/1/20219/1/20209/1/2021
<br />POLICY EFFPOLICY EXP
<br />(MM/DD/YYYY)(MM/DD/YYYY)
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORETHE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED INACCORDANCE WITH THE POLICY PROVISIONS.
<br />CONTACTNAME:PHONE(A/C, No, Ext):E-MAILADDRESS:INSURER A :INSURER B :INSURER C :INSURER D :INSURER E :INSURER F :CANCELLATION AUTHORIZED REPRESENTATIVE
<br />POLICY NUMBER
<br />5431028154310280ZUP-91N03112-20-NF54310282
<br />X
<br />The ACORD name and logo are registered marks of ACORD
<br />INSDWVDN / A
<br />ADDLSUBR
<br />CERTIFICATE OF LIABILITY INSURANCE
<br />N
<br />Y / N
<br />CERTIFICATE NUMBER:
<br />10,000
<br />LOC
<br />OCCURCLAIMS-MADE
<br />SCHEDULEDNON-OWNED
<br />XX
<br />PRO-JECT
<br />X
<br />X
<br />TYPE OF INSURANCE
<br />T.E. Roberts, Inc.306 W. Katella Ave Unit BOrange, CA 92867
<br />City of Santa AnaRisk Management Division20 Civic Center PlazaSanta Ana, CA 92701
<br />CLAIMS-MADEOCCUR
<br />License # 0757776
<br />COMMERCIAL GENERAL LIABILITYPOLICYOTHER:ANY AUTOOWNEDAUTOS ONLYAUTOSHIREDAUTOS ONLYAUTOS ONLYUMBRELLA LIABEXCESS LIABDEDRETENTION$
<br />XXX
<br />GEN'L AGGREGATE LIMIT APPLIES PER:AUTOMOBILE LIABILITY
<br />WORKERS COMPENSATIONAND EMPLOYERS' LIABILITYANY PROPRIETOR/PARTNER/EXECUTIVEOFFICER/MEMBER EXCLUDED?(Mandatory in NH)If yes, describe underDESCRIPTION OF OPERATIONS below
<br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THISCERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,
<br /> EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIESBELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZEDREPRESENTATIVE
<br /> 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
<br /> SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement onthis certificate does not confer rights
<br /> to the certificate holder in lieu of such endorsement(s).THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE
<br /> POLICY PERIODINDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THISCERTIFICATE MAY BE ISSUED OR MAY
<br /> 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
<br /> BY PAID CLAIMS.
<br />ABCB
<br />PRODUCERINSURED COVERAGES DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)CERTIFICATE HOLDERACORD
<br /> 25 (2016/03)
<br />LTR
<br />INSR
<br />Newport Beach, CA - HUB International Insurance Services Inc.4695 MacArthur CourtSuite 600Newport Beach, CA 92660
<br />Re: Emergency Sewer and Water System Repair Services.The City of Santa Ana, its officers, employees, agents, and representatives are included as additional insured as respects general
<br /> liability, as required by written contract, and is primary and non-contributory, subject to the terms and conditions of the policy and attached forms. Separation of Insureds applies.30
<br /> day notice of cancellation, except 10 days for non-payment.
<br />
<br />
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