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Di9iay signed by <br />Francine R. <br />Francine R. Villareal <br />Villareal Date: 2021.07.2910:16:52 Page 1 of 2 <br />n7'nn' <br />C^ Rio> <br />AC" CERTIFICATE OF LIABILITY INSURANCE <br />(MMIDDIYYYY) <br />705/21/2021 <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 <br />Willis (Bermuda) Ltd. <br />Wellesley House, Ind Floor <br />90 Pitts Bay Road <br />CONTACT Willis Towers Watson Certificate Center <br />NAME: <br />PHONE 1-877-945-7378 FAX 1-888-467-2378 <br />AIC No Ext : AIC, No): <br />E-MAIL certificates@willis.com <br />ADDRESS: <br />INSURER(S) AFFORDING COVERAGE <br />NAIC# <br />Pembroke, HM08 B14U <br />INSURER A: American Unity Group Limited <br />C0929 <br />INSURED <br />Taller San Jose Hope Builders <br />INSURER B : <br />801 N. Broadway <br />INSURER C <br />INSURER D <br />Santa Ana, CA 92701 <br />INSURER E <br />INSURER F : <br />COVERAGES CERTIFICATE NUMBER: W21008985 REVISION 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 />INSR <br />LTR <br />TYPE OF INSURANCE <br />ADDL <br />INSD <br />SUBR <br />WVD <br />POLICY NUMBER <br />POLICY EFF <br />MMIDDIYYYY <br />POLICY EXP <br />MMIDDIYYYY <br />LIMITS <br />X <br />COMMERCIAL GENERAL LIABILITY <br />EACH OCCURRENCE <br />$ 3,000,000 <br />X CLAIMS -MADE OCCUR <br />DAMAGE TRENTE <br />PREM SESOE. occurrDence <br />$ <br />MED EXP (Any one person) <br />$ <br />A <br />y <br />1-14601-00-21 <br />06/01/2021 <br />06/01/2022 <br />PERSONAL & ADV INJURY <br />$ <br />GEN'L <br />AGGREGATE LIMIT APPLIES PER: <br />GENERAL AGGREGATE <br />$ 5,000,000 <br />POLICY ❑ PRO ❑ <br />JECT LOC <br />X <br />PRODUCTS - COMP/OP AGG <br />$ <br />$ <br />OTHER: <br />AUTOMOBILE LIABILITY <br />C OMBINED SINGLE LIMIT <br />Ea accident <br />$ <br />BODILY INJURY (Per person) <br />$ <br />ANY AUTO <br />OWNED SCHEDULED <br />AUTOS ONLY AUTOS <br />BODILY INJURY (Per accident) <br />$ <br />PROPERTY DAMAGE <br />Per accident <br />$ <br />HIRED NON -OWNED <br />AUTOS ONLY AUTOS ONLY <br />L <br />$ <br />UMBRELLALIAB <br />OCCUR <br />EACH OCCURRENCE <br />$ <br />AGGREGATE <br />$ <br />EXCESS LAB <br />CLAIMS -MADE <br />DED RETENTION $ <br />$ <br />WORKERS COMPENSATION <br />AND EMPLOYERS' LIABILITY YIN <br />PER OTH- <br />STATUTE ER <br />ANYPROPRIETOR/PARTNER/EXECUTIVE <br />E.L. EACH ACCIDENT <br />$ <br />OFFICER/MEMBER EXCLUDED? ❑ <br />N I A <br />E.L. DISEASE - EA EMPLOYEE <br />$ <br />(Mandatory in NH) <br />If yes, describe under <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 />AUTHORIZED REPRESENTATIVE <br />City of Sana Ana Risk Management Division <br />20 Civic Center Plaza <br />Santa Ana, CA 92702 <br />© 1988-2016 ACORD <br />ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD <br />SR ID: 21126221 BATCH: 2103724 <br />�oRaN RiskMmRgemerdDivisilm <br />REVIEWED & APPROVED BY. - <br />Risk Management Analyst <br />