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<br />INHIP Y
<br />DATE IM9/12/20192019 I
<br />A%. i CERTIFICATE OF LIABILITY INSURANCE
<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 pollcy(les) 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($).
<br />PRODUCER License # 0757776
<br />c TAcT Kimberly Shippey
<br />Newport Beach, CA - HUB International Insurance Services Inc.
<br />4695 MacArthur Court, Suite 600
<br />Newport Beach, CA 92660
<br />PHONE Fez
<br />arc No, Ertl: c NgI:
<br />I� . kimberly.shi ahubinternafional.com
<br />INSURGRISI AFFORDING COVERAGE NAIC#
<br />INSURERA:Old Republic General Insurance Cori).
<br />24139
<br />INSURED
<br />IN URERB,Travellem Property Casualty Company of America
<br />26674
<br />IN UREa :
<br />T.E. Roberts, Inc.
<br />INSURER D:
<br />306 W. Katella Ave Unit B
<br />Orange, CA 92867
<br />INSURE0. E:
<br />INSURER F :
<br />COVERAGES CERTIFICATE NUMBER: REVISION NUMRER- 01
<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 />WSR 118.
<br />TYPE OF INSURANCE
<br />ADOL
<br />SUER
<br />POLICY NUMBER
<br />POLICY lFF
<br />POLICY E%P
<br />I
<br />LIMITS
<br />A
<br />X
<br />COMMERCUILGENERALLIABILnY
<br />LLMMS-MADE X OCCUR
<br />❑
<br />X
<br />AlCG13971801
<br />911I2019
<br />9/1/2020
<br />EACH OCCURRENCE
<br />S 1,000,006
<br />DAMAGE TO RENTED
<br />100,000
<br />S 51000
<br />MED EXP "
<br />PERSONAL S ADV INJURY
<br />S 1,000,000
<br />NL AGGREGATE UNIT APPLIES PER:
<br />POLICY j ❑ LOG
<br />GENERALAGGREGATE
<br />S 2,000,000
<br />PRODUCTS - COMPIOP AGG
<br />S 2,000,000
<br />S
<br />OTHER:
<br />A
<br />AUTOMOSILELIABILITY
<br />OMBINEO SINGLE LIMIT
<br />1,000.00D
<br />X
<br />ANY AUTO
<br />OWNED
<br />AUTOS ONLY SCJH
<br />t
<br />1CA13971801
<br />91112019
<br />W1/2D20BODILYINJURY
<br />Pa rn
<br />BODILY INJURY Per accident]
<br />S
<br />4:ta4ZOAMAGE
<br />XAUONLY
<br />�ULED
<br />ApRTapp
<br />S
<br />B
<br />X
<br />UMBRELLA LINE
<br />L X
<br />OCCUR
<br />EACH OCCURRENCE
<br />10,000,000
<br />EXCESS LIRE
<br />CtAIM'MADE
<br />UP-91NO3112.19-NF
<br />911/2019
<br />911/2020
<br />AGGREGATE
<br />DED X RETENTION$ 10,000
<br />S 10,000,000
<br />A
<br />WORKERS COMPENSATION
<br />AND EMPLOYERTLUUNLItt
<br />ANY PROPRIETORIPARTNER/EXECUTIVE YIN
<br />O�FFFICERIMEEM99��pp EXCLUDED? ❑
<br />'$tndaloryln NN)
<br />N yea.4e"o"N wMer
<br />DE CRIPTI NOF PERATIONS
<br />NiA
<br />lCW13971801
<br />91112019
<br />91112020
<br />)( PER H-
<br />E.L EACH ACCIDENT
<br />S 1,000,000
<br />E.L DISEASE- EA EMPLOYEE
<br />3 1,000,00D
<br />L DISEASE -POLICY MIT
<br />1,000,000
<br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES 1ACOAD t01, A441aonal RenuMP S[M1etlule,,,py bo alMNed ll ma,e ape<e la requFatll
<br />Re: Agreement for #8208 -On Call Sewer and Water System Repair Services; A-2019-0142-03, A-2014-230-01, IFB 16.104 Water Meter Vault Replacement
<br />City of Santa Ana, Its officers, employees, agents, volunteers and representatives are included as additional Insureds, as respects general liability and auto
<br />liability, which is primary and non-contributory, subject to the terms and conditions of the policy, and attached forms. Separation of Insureds applies. 30
<br />days notice of cancellation, 10 days for non-payment of premium.
<br />REVIEWED & APPROVED
<br />By Rift MANACfEMENT DIVISION
<br />CERTIFICATE HOLDFR It I eCD 1 O 9ngn rAIJr GI I ATIMM
<br />OIJLO ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />City of Santa Ana SA THA M. LAMBE
<br />KHE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />CCORDANCE WITH THE POLICY PROVISIONS.
<br />Risk Management Division, 4th Floor
<br />20 Civic Center Plaza
<br />AUTHORIZEDDR,EEPJRESENTATIVE
<br />Santa Ana, CA 92702
<br />rj,To('� 1V1 dL_
<br />ACORD 25 (2016103) 01988.2015 ACORD CORPORATION. All rights reserved.
<br />The ACORD name and logo are registered marks of ACORD
<br />
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