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<br />ACCW& CERTIFICATE OF LIABILITY INSURANCE
<br />11hi
<br />DATE(MMMD/VYYY)
<br />1 8/10/2020
<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
<br />HUB International Insurance Services Inc.
<br />3636 American River Drive, Suite 200
<br />Sacramento CA 95864
<br />License#: 0757776
<br />CONTACT
<br />NAME: ROCIO Leon
<br />IPA
<br />HONE 916-480-4134 A/c Not:916-993-7234
<br />n D LESS: Rocio.Leon@hubinternational.com
<br />INSURERS AFFORDING COVERAGE
<br />NAIC#
<br />INSURER A: Greenwich Insurance Company
<br />22322
<br />INSURED WAREOIS-02
<br />Madison Materials
<br />P.O. Box 1318
<br />Santa Ana CA 92702
<br />INSURER B: Westchester Surplus Lines Insurance Co.
<br />10172
<br />INSURER c: Alaska National Insurance Company
<br />38733
<br />INSURERD: Indian Harbor Insurance Company36940
<br />INSURER E :
<br />INSURER F:
<br />COVERAGES CERTIFICATE NUMBER-B7S90c9AR Dclnctnu NUMBED.
<br />THIS 15 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 />gDOL
<br />SUBS
<br />POLICY NUMBER
<br />POLICY EFF
<br />MM/DDIYNNYT,
<br />POLICY EXP
<br />1MM1DDVyYyYI
<br />LIMITS
<br />A
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />Y
<br />GEC3D00730-05
<br />2/28/2020
<br />k'
<br />EACHOCCURRENCE
<br />$1.000,000
<br />PREMISES Ea occurrence)
<br />$100,000
<br />CLAIMS -MADE OCCUR
<br />X
<br />MED EXP ) (Any one person
<br />$ 5,000
<br />$1,0M PC Ded.
<br />Per Occurrence
<br />PERSONAL& ADV INJURY
<br />1,0013,000
<br />GEN'L
<br />AGGREGATE LIMIT APPLIES PER:
<br />GENERAL AGGREGATE
<br />_$
<br />$2,000,000
<br />POLICY [X]JEo
<br />LOG
<br />PRODUCTS -COMP/OPAGG
<br />$2,000,000
<br />$
<br />OTHER:
<br />A
<br />AUTOMOBILE
<br />LIABILITY
<br />Y
<br />AE0004538605
<br />2/28/2020
<br />2/$By202T
<br />EOaBIINdEeDtSINGLELIMIT
<br />$1,000,000
<br />ANY AUTO
<br />X
<br />BODILY INJURY tPerperson)
<br />$
<br />OWNED SCHEDULED
<br />1
<br />AUTOS ONLY AUTOS
<br />BODILY INJURY (Per accident)
<br />$
<br />HIRED NON -OWNED
<br />AUTOS ONLY AUTOS ONLY
<br />PROPERTY DAMAGE
<br />Per accident
<br />$
<br />BIIPD Deductible
<br />$10,000
<br />B
<br />UMBREUAUR8
<br />X
<br />OCCUR
<br />G46863306003
<br />2/28/2020
<br />--2/2872021-
<br />EACH OCCURRENCE
<br />$10,000,000
<br />X
<br />AGGREGATE
<br />$10,000,000
<br />EXCESS LIAB
<br />CLAIMS -MADE
<br />LIED I I RETENTION$
<br />s
<br />C
<br />WORKERS COMPENSATION
<br />20H WS 05450
<br />8A/2020
<br />--B/1'/2021
<br />X
<br />I
<br />AND EMPLOYERS' LIABILITY YIN
<br />STATUTE EORH
<br />E.L. EACH ACCIDENT
<br />$ 1,000,000
<br />ANYPROPRIETORIPARTNERIEJ(ECUTIVE
<br />OFFICERIMEMBER EXCLUDED?
<br />NIA
<br />E.L. DISEASE -EA EMPLOYEE
<br />$1,000.000
<br />(Mandatory in NH)
<br />If yes, describe under
<br />E.L DISEASE -POLICY LIMIT
<br />$1,000,000
<br />DESCRIPTION OF OPERATIONS below
<br />D
<br />Pollution & Remediation Legal
<br />PECO056139
<br />2/28/2020
<br />212812023.
<br />Each Poll Condition
<br />$5,000,000
<br />Liability/CPL
<br />Aggregate
<br />$10,000,000
<br />Retention
<br />$10.000
<br />DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORO 101, Additional Remarks Schedule, may be attached if more space is required)
<br />(General Liability Per Project Aggregate applies per written contract)
<br />Re: Work performed by the insured for Certificate holder per written contract
<br />Additional Insured: City of Santa Ana, its officers, employees, agents and representatives are additional insured with respects to General Liability and Auto
<br />Liability as required per written contract
<br />Forms: CG2010 0413, CG2037 0413, IXI405 0910, XIL431 0605, XIC411 1013
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />City of Santa Ana ACCORDANCE WITH THE POLICY PROVISIONS.
<br />Risk Management Division, 4th Floor
<br />20 Civic Center Plaza AUTHORIZED REPRESENTATIVE
<br />Santa Ana CA 92701 RMeldanagenlod.DMam
<br />REVIEwEo & MPRav® BY:
<br />©19B8-2015ACORDC q . 1 J' F4.#.n.6L44 p. V1(.4vaLI
<br />ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD'' Risk Management Analyst
<br />
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