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Digitally signed by Francine R.
<br />Francine R. Villareal Villareal
<br />nary 1 m 1 s 1 n lrm-ns,nrr
<br />ACOR" CERTIFICATE OF LIABILITY INSURANCE
<br />lill
<br />DATE(MM/°DIYYYY)
<br />1 1 /11 /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 />Bolton & Company
<br />CONTACT
<br />NAME:
<br />3475 E. Foothill Blvd., Suite 100
<br />Pasadena, CA 91107
<br />HONAic,No Ext: 626 799 7000 A/c, No: 626 583 2117
<br />E-MAIL
<br />ADDRESS:
<br />INSURER(S) AFFORDING COVERAGE
<br />NAIC #
<br />INSURER A: Greenwich Insurance Company
<br />22322
<br />www.boltonco.com 0008309
<br />INSURED
<br />United Storm Water, Inc.
<br />14000 East Valley Blvd.
<br />INSURER B : XL Insurance America, Inc.
<br />24554
<br />INSURERC: Indian Harbor Insurance Company
<br />36940
<br />INSURER D
<br />City of Industry CA 91746
<br />INSURER E
<br />INSURER F :
<br />COVERAGES CERTIFICATE NUMBER: F4F.9F�� 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 />OF INSURANCE
<br />ADDLTYPE
<br />INSD
<br />WVDUBR
<br />POLICY NUMBER
<br />POLICYEFF
<br />MMDDIYYYY
<br />POLICYEXP
<br />MMDDIYYYY
<br />LIMITS
<br />A
<br />`/
<br />COMMERCIAL GENERAL LIABILITY
<br />✓
<br />GEC3001234
<br />12/31/2020
<br />12/31/2021
<br />EACH OCCURRENCE
<br />$1,000,000
<br />CLAIMS -MADE 1/ OCCUR
<br />DAMAGE TO RENTED
<br />PREMISES Ea occurrence
<br />$ 100,000
<br />MED EXP (Any one person)
<br />$ 5,000
<br />PERSONAL & ADV INJURY
<br />$1,000,000
<br />GEN'L
<br />AGGREGATE LIMIT APPLIES PER:
<br />GENERAL AGGREGATE
<br />$ 2,000,000
<br />POLICY ✓� PE� LOC
<br />PRODUCTS - COMP/OP AGG
<br />$ 2,000,000
<br />$
<br />OTHER:
<br />B
<br />AUTOMOBILE LIABILITY
<br />AECO048938/AECO048939
<br />12/31/2020
<br />12/31/2021
<br />COMBINED
<br />(EaMBI EDtSINGLELIMIT
<br />$1,000,000
<br />BODILY INJURY (Per person)
<br />$
<br />✓ ANY AUTO
<br />BODILY INJURY (Per accident)
<br />$
<br />OWNED SCHEDULED
<br />AUTOS ONLY AUTOS
<br />PROPERTY DAMAGE
<br />Per accident
<br />$
<br />HIRED NON -OWNED
<br />✓ AUTOS ONLY ✓ AUTOS ONLY
<br />C
<br />UMBRELLALIAB
<br />�/
<br />OCCUR
<br />UECO048940
<br />12/31/2020
<br />12/31/2021
<br />EACH OCCURRENCE
<br />$15,000,000
<br />v1
<br />AGGREGATE
<br />$ 15,000,000
<br />EXCESS LIAB
<br />CLAIMS -MADE
<br />DED ✓ RETENTION $10,000
<br />$
<br />A
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY Y I N
<br />ANYPROPRIETOR/PARTNER/EXECUTIVE
<br />OFFICER/MEMBER EXCLUDED? ❑N
<br />NIA
<br />WEC3001235
<br />12/31/2020
<br />12/31/2021
<br />✓ PEATUTE EORH
<br />E.L. EACH ACCIDENT
<br />$ 1,000,000
<br />E.L. DISEASE - EA EMPLOYEE1
<br />$1,000,000
<br />(Mandatory in NH)
<br />If yes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />E.L. DISEASE - POLICY LIMIT
<br />1 $1,000,000
<br />C
<br />Pollution Liability
<br />PECO048963
<br />12/31/2020
<br />12/31/2021
<br />$15,000,000 Occ/Aggregate / $25,000 Died.
<br />C
<br />Professional Liab - Claims Made
<br />PECO048963
<br />12/31/2020
<br />12/31/2021
<br />$15,000,000 Each Claim/Agg / $25,000 Died.
<br />DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
<br />Re: Agreement #A-2017-157, A-2020-079 (1st Amendment), A-2020-158-06 (2nd Amendment), and A-2020-158-29 (3rd Amendment) in City of Santa Ana.
<br />GL Additional Insured applies per CG20101219 & CG20371219 attached, only if required by written contract/agreement.
<br />GL Primary & Non -Contributory Wording applies per XIL4240605 attached. Excess Policy follows form.
<br />Additional Insured(s): City of Santa Ana, its officers, agents, volunteers and employees.
<br />CERTIFICATE HOLDER
<br />CANCELLATION
<br />Agreement #A-2017-157
<br />City of Santa Ana
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL
<br />CANCELLED BEFORE
<br />BE DELIVERED IN
<br />Risk Management Division
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />20 Civic Center Plaza
<br />Santa Ana, CA 92702
<br />AUTHORIZED REPRESENTATIVE
<br />Risk Mawagimu2dDivision
<br />Cassandra Rosales
<br />r% \q
<br />REVIEWED&APPROVED By.
<br />© 1988-2015 ACORD C
<br />ACORD 25 (2016/03)
<br />The ACORD name and logo are registered marks of ACORD
<br />Risk Management analyst
<br />59552633 I UNITPUM-01 120-21 All Lines
<br />Cary Hospedales 11/11/2021 3:53:53 PM (PST) I Page 1 of 5
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