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Digitally signed by <br />Francine R. <br />Francine R. Villareal <br />Villareal Date: 2021.01.2815:53:17 <br />08'00' <br />DATE (MMIODNYYY) <br />ACOR" CERTIFICATE OF LIABILITY INSURANCE �5/29/2020 <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. A statement on <br />this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). <br />PRODUCER CONTACT Willis Towers Watson Certificate Center <br />NAME: <br />Willis (Bermuda) Ltd. """""" - <br />PHONE 1-877-945-7378 FOX 1-888-467-2378 <br />Wellesley House, 2nd Floor d�*'+�.l�.a...E.�tl� �� .Mo)� .,n .._. <br />E-MAIL certificates@willia.com <br />90 Pitts Bay Road ADDRESS _ <br />Pembroke, HM08 EMU -.,m .. .m-� ..,,m ...-...a� <br />I� _ _ AFFORD NG COVERAGE_ NAIC #_ <br />INSURER�S� 1 <br />INSURER A : American Unity Group Limited C0929 <br />INSURED INSURER B : <br />Taller san Jose <br />801 N. Broadway INSURERC <br />Santa Ana, CA 92701 INSURER D <br />CAVFRAGF3 CERTIFICATE NUMBER: W16573773 RFVISIIJN NUMBER: <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 />ILTR NSR <br />ADDL <br />SUER-. <br />POLICY EFF <br />POLICY EXP <br />TYPE OF INSURANCE <br />POLICY NUMBER <br />MMIDD(YYYY) <br />JMM DDIYYYY <br />LIMIT'S <br />X <br />COMMERCIAL GENERAL LIABILITY <br />EACH OCCURRENCE <br />$ 3,000,000 <br />_--� <br />X <br />DAMAGE TO RENTED <br />..... .....,a, <br />CLAIMS -MADE OCCUR <br />PREMISES (Ea occurrence)-„ „_ <br />$ __ <br />A <br />MED EXP (Any one person) <br />$ <br />........,..i <br />,_............................................................................-..,,,-,.......... <br />.... m <br />y <br />1-14601-00-20 <br />06/O1/2020 <br />06/O1/2021 <br />RY <br />..-.-......-._---„.,.,.w.. <br />,. <br />$ .........---... __..— <br />GEN'L <br />AGGREGATE LIMIT APPLIES PER <br />GENERAL AGGREGRE GATE <br />$ 5,000,000 <br />%S <br />PRO- <br />POLICY LOC <br />JECT <br />PRODUCTS-COMPIO. <br />P AGG <br />$ - � _- <br />OTHER: <br />$ <br />AUTOMOBILE LIABILITY <br />COMBINED SINGLE LIMIT <br />$ <br />(E Waccidenl).... . <br />ANY AUTO <br />BODILY INJURY (Per person) <br />S <br />OWNED SCHEDULED <br />BODILY INJURY (Per <br />AUTOS ONLY AUTOS <br />$ <br />HIRED <br />—� NUN-OWNLDY <br />bAMAGEaccidenQ <br />........... <br />P...... ONLY <br />.�„�bPR, <br />UMBRELLA LIAB OCCUR <br />ACH OCCURRENCE <br />E � <br />$ _�......_........ rv.,.,.... <br />EXCESS IGGREGATE <br />- <br />A <br />$ <br />DIED J. RETENTIONS <br />$ <br />WORKERS COMPENSATION <br />PER <br />I <br />AND EMPLOYERS' LIABILITY Y I N <br />STATUTE EORH <br />E.L. EACH AC <br />$ <br />OFFICERIMEMBEREXCLUOED7 <br />NIA <br />CEDAENT <br />(Mandatory nTNH)PARTNERIEXECUTIVE <br />E.L. DISEASE EMPLOYEE <br />S <br />It yes, describe under <br />"'"'"'"'"'- <br />DESCRIPTION OF OPERATIONS below <br />E.L. DISEASE - POLICY LIMIT <br />$ <br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) <br />If this Certificate of Insurance is for Professional and / or General Liability insurance this provides evidence of <br />coverage for 1) employees while acting within the scope and during the course of their employment with Providence St. <br />Joseph Health and /or 2) contracted parties for their acts, errors or omissions in rendering or failing to render <br />Medical Services outlined by such contract with a Providence St. Joseph Health entity including the Insured identified <br />on this certificate. <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 />RAUTHORIZED REPRESENTATIVE <br />Risk Management Division <br />20 Civic Center Plaza �,- <br />r <br />Santa Ana, CA 92702 <br />© 1988-2016 ACORD CO �F Is,sleTAa�agelnentDtnawn <br />r% t REVIEWED & APPROVED BY.- <br />ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD <br />sR xo: 19650047 BATCH: 1693972 mC P, <br />Mud <br />-��" Risk Management Analyst <br />