|
Page 1 of 2
<br />ACC)Rbr CERTIFICATE OF LIABILITY INSURANCE
<br />oATE(MM1DDNYYY)
<br />1�
<br />10/03/2019
<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(s).
<br />PRODUCER
<br />CONTACT
<br />ONT
<br />Willie Toexs Watson Insurance Services west, Inc. fka Willie
<br />PHONE 1-877-945-7378 1-888-9fi7-2378
<br />CNal:.
<br />Insurance Services of California, In°.
<br />pOAlESs: certificates@willis.com
<br />c/o 26 Century Blvd
<br />P.O. Has 305191
<br />INSURERJS)AFFOROINGCOVERAGE
<br />NAICt1
<br />Nashville, TN 372305191 USA
<br />INSURERA: Lexington Insurance Company
<br />19437
<br />INSURED
<br />INSURERS: Greenwich Insurance Company
<br />22322
<br />The Salvation Army - Division 11
<br />INSURERC; M Specialty Insurance Company
<br />37085
<br />30840 Hawthorne Blvd., Bldg D
<br />INSURER O;
<br />Rancho Palos Vezdea, CA 90275
<br />INSURER. E:
<br />INSURERF:
<br />COVERAGES CERTIFICATE NUMBER: W13279389 ..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 />INTR
<br />TYPEOFINSURANCE
<br />A
<br />$WIR
<br />POUCYNUMaER
<br />PODD F
<br />IPOIODN P
<br />LIMITS
<br />A
<br />X
<br />COMMERCIALGENERALLIABILITY
<br />CLAIMS -MADE OXOCCUR
<br />SIR: $500,000 Par Occurrence
<br />y
<br />021H2409
<br />10/01/2019
<br />_
<br />10/01/2020
<br />EACH OCCURRENCE
<br />§ 2,000,000
<br />-GANTAGETO-R€NTEO
<br />scaur'.Mal
<br />$ 11000, 000
<br />X
<br />_PREMISESlEp
<br />MEO E%P IAny`one anon)
<br />$ 0
<br />PERSONAL&ADV INJURY
<br />$ 2,000,000
<br />IES PER;
<br />APIIP"L�jj
<br />POLICY CJjE T I_^J LOC
<br />4ENERALAGGREGATE
<br />$ _. 4,000,000
<br />GEN'LAGOREGATEILIMIT
<br />-
<br />RODUCTS-COMWOPAGG_
<br />$ 4IOODIODO
<br />I
<br />$
<br />OTHER:
<br />---
<br />AUTOMOBILELIAHILITY
<br />Ee OMBIFI®SINGLE LIMIT
<br />a¢idvh -
<br />S 51000,000
<br />AUTO
<br />BODILY INJURY(Par Person)eOWNED
<br />AWNED ONLY AUTOS
<br />AUTOSSCHEDULED
<br />Y
<br />RAD5000219-09
<br />10/01/2019
<br />10/01/2020
<br />BODILY INJURY
<br />$
<br />nANY
<br />HIRED NON-0WNED
<br />AUTOS ONLY AUTOS ONLY
<br />PROPERTY OAMAGC
<br />1per dcddaJ_
<br />_
<br />$
<br />UMBRELLALIA9
<br />OCCUR
<br />EACH OCCURRENCE
<br />$
<br />EXOESH LIAB _
<br />_
<br />_
<br />CLAIMS-MAOE
<br />AGGREGATE_
<br />$
<br />DED
<br />RETENTION$
<br />s
<br />E
<br />C
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS'LIABILITY Y/N
<br />ANYPROPRIETORIPARTNERIEXECUTIVE
<br />OFFICEMMEMBEREXCLUDED7
<br />N/A
<br />Y
<br />RM5000217-09
<br />10/01/2019
<br />10/01/2020
<br />X Eft OTH-
<br />STTUTE
<br />E.L. EACH ACCIOEM
<br />$ 1,000,000
<br />E.L. DISEASE -EA EMPLOYEE
<br />8 1, 00010U0
<br />(Mandatory In NH)
<br />d e5, dexr0e order
<br />DESCRIPTION OF OPERATIONS below
<br />E.L. UISEABE-POLICY LIMIT
<br />§ 1, 000,000
<br />C
<br />Excess Workers Compensation
<br />Y
<br />RWE500021609
<br />10/01/2019
<br />10/01/2020
<br />H.L. Each Accident
<br />$1,000,000
<br />and Employerfa Liability
<br />E.L. Disease Pot Lim
<br />$1,000,00o
<br />INC - Per Statute
<br />E.L. Disease - Ea Em
<br />$1,000,000
<br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedola, may be attached it more apace Is required)
<br />Division 011-148
<br />Workers Compensation:
<br />Policy No. RWD5000217-09 provides coverage in the following states: HI,ID,24T,NM,NV,TX,UT
<br />Policy No. RWES00021609 provides coverage in the following states: AE,CO,OR
<br />SEE ATTACHED
<br />.CERTIFICATE HOLDER CANCELLATION
<br />REVIEWED & APPROVED
<br />By Risk MANAGCMENT DIVISION
<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 />T 0 3 D19
<br />City of Santa Ana
<br />AUTFIORIZED REPRESENTATIVE
<br />Risk Management Division
<br />20 Civic Center 0aaa
<br />RAN ,I 2. VILLAREAL
<br />11��
<br />Santa Ana, CA 92702
<br />,0
<br />©1988-2016 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
<br />SR to: 18625509 9Arca: 1395011
<br />
|