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Francine R.
<br />ADAMSTR-01Villareal
<br />Digitally signed by
<br />Francine F. Villareal
<br />Date'. mm.DSJ1 14 43 54
<br />-D"D MCGRAWM
<br />CERTIFICATE OF LIABILITY INSURANCE
<br />DAT91312 DI020
<br />9/3/20
<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 License # OE67768
<br />CONTACT Dana Schwartz
<br />NAME:
<br />PHONE FAX
<br />(A/C, No, Ext): (619) 574-6223 50203 (AIO, Nop(619) 574-6288
<br />IDA Insurance Services
<br />4370 La Jolla Village Drive
<br />Suite 600
<br />ADDRESS: Dana.Schwartz@ioausa.com
<br />San Diego, CA 92122
<br />INSURER(S)AFFORDING COVERAGE
<br />NAIC#
<br />INSURERA: RLI Insurance Company
<br />13056
<br />INSURED
<br />INSURERS Begazley Insurance Company,Inc
<br />37540
<br />INSURERC:
<br />Adams Streeter Civil Engineers, Inc.
<br />INSURERD:
<br />16755 Von Karman, Suite 150
<br />Irvine, CA 92606
<br />INSURERE:
<br />INSURERF:
<br />COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
<br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BE LOW HAVE BEEN ISSUED TOTH E INSURED NAMED ABOVE FORTH E POLICY PERIOD
<br />INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
<br />CERTIFICATE MAYBE 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 LTR
<br />TYPE OF INSURANCE
<br />ADDL
<br />SUBR
<br />POLICY NUMBER
<br />POLICY EFF
<br />POLICY EXP
<br />LIMITS
<br />A
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />EACH OCCURRENCE
<br />$ 1,000,000
<br />CLAIMS -MADE X OCCUR
<br />X
<br />X
<br />PSB0001237
<br />9/1/2020
<br />9/1/2021
<br />DAMAGE TO RENTED
<br />PREMISES Ea occurrence
<br />1,000,000
<br />$
<br />X
<br />MED EAR Anv one arson
<br />$ 10,000
<br />Contractual Liab.
<br />X
<br />Sev. of Interests
<br />PERSONAL &ADS INJURY
<br />$ 1,000,000
<br />GEN'L
<br />AGGREGATE LIMIT APPLIES PER
<br />GENERAL AGGREGATE
<br />$ 2,000,000
<br />POLICY PRO LOC
<br />PRODUCTS - COMP/OP AGO
<br />$ 2,000,000
<br />Deductible
<br />$ 0
<br />OTHER..
<br />A
<br />AUTOMOBILE
<br />LIABILITY
<br />COMBINED SINGLE LIMIT
<br />Ea accident
<br />1,000,000
<br />$
<br />X
<br />BODILY INJURY Per arson
<br />$
<br />ANY AUTO
<br />X
<br />X
<br />PSA0001063
<br />9/1/2020
<br />9/1/2021
<br />OWNED SCHEDULED
<br />AUTOSONLYAUTOS
<br />BODILY INJURY (Per accident)
<br />$
<br />HIRED
<br />AUTOSONLY
<br />Coll $500
<br />Comp. $500 Ix
<br />PROPERTY
<br />accidenDAMAGE
<br />$
<br />X
<br />A
<br />X
<br />UMBRELLALIAB
<br />X
<br />OCCUR
<br />EACH OCCURRENCE
<br />$ 3,000,000
<br />EXCESS LIAB
<br />CLAIMS -MADE
<br />PSE0001201
<br />9/1/2020
<br />9/1/2021
<br />AGGREGATE
<br />$ 3,00l
<br />DED X RETENTION$ 0
<br />A
<br />WORKERS COMPENSATION
<br />ANDEMPLOVERS'LIABILITY
<br />ANY PROPRIETOR/PARTNER/EXECUTIVEVD
<br />OFFICER/MEMBER EXCLUDED?
<br />(Mandatory in NH)
<br />N/A
<br />X
<br />PSW0001554
<br />9/1 /2020
<br />9/1 /2021
<br />X PER OTH-
<br />STATUTE ER
<br />EL EACH ACCIDENT
<br />1,000,000
<br />$
<br />E. L. DISEASE - EA EMPLOYEE
<br />$ 1,000,000
<br />ryes describe under
<br />DESCRIPTION OF OPERATIONS below
<br />EL.DISEASE -POLICY LIMIT
<br />1,000,000
<br />$
<br />B
<br />Prof Liab/Clms Made
<br />V21 EE9200301
<br />2/13/2020
<br />2/13/2021
<br />Per Claim
<br />2,000,000
<br />B
<br />Ded.: $40k Per Claim
<br />V21 EE9200301
<br />2/13/2020
<br />2/13/2021
<br />Aggregate
<br />4,000,000
<br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
<br />Re: All operations
<br />City of Santa Ana, officers, agents, employees, and volunteers are Additional Insureds with respect to General and Auto Liability per the attached
<br />endorsements as required by written contract. Insurance is Primary and Non -Contributory. Waiver of Subrogation applies to General Liability, Auto Liability
<br />and Workers' Compensation.
<br />30 Days Notice of Cancellation with 10 Days Notice for Non -Payment of Premium in accordance with the policy provisions.
<br />City of Santa Ana
<br />Risk Management Division
<br />20 Civic Center Plaza
<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 />oliaJJ y 4441
<br />ACORD 25 (2016/03) © 1988-2015 ACORD
<br />The ACORD name and logo are registered marks of ACORD
<br />— "coneKerneru un,aa,rr
<br />Z REVIEWED &APPROVED BY:
<br />® Risk Management Analyst
<br />
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