|
Digitally signed by Francine R.
<br />Francine R. Villareal Villareal
<br />Date: 2021.08.241725:18-07'00'
<br />PALELLC-01 EPRENTISS
<br />,d►c - CERTIFICATE OF LIABILITY INSURANCE
<br />��
<br />DAT/18/2D/Y1
<br />8/18/2021
<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 />CONTACT
<br />NAME:
<br />PHONE FAX
<br />(A/C, No, Ext): (602) 992-9750 (A/C, No):(602) 992-9775
<br />AssuredPartners
<br />7500 N. Dreamy Draw Dr., Ste. 100
<br />Phoenix, AZ 85020
<br />E-MAIL
<br />DD RIESS:
<br />INSURERS AFFORDING COVERAGE
<br />NAIC #
<br />INSURERA:Charter Oak Fire Ins. Co.
<br />25615
<br />INSURED
<br />INSURERB: Phoenix Insurance Company
<br />25623
<br />INSURER C : Travelers Prop Cas Co of Amer
<br />25674
<br />PaleoWest, LLC
<br />INSURER D : Landmark American Insurance Co
<br />33138
<br />319 E. Palm Lane
<br />Phoenix, AZ 85004
<br />INSURER E: The Continental Insurance Company
<br />35289
<br />INSURER F :
<br />COVERAGES CERTIFICATE NUMBER: 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 />MM/DD/YYYY
<br />POLICY EXP
<br />MM/DD/YYYY
<br />LIMITS
<br />A
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />EACH OCCURRENCE
<br />$ 1,000,000
<br />CLAIMS -MADE j OCCUR
<br />6307NO28185
<br />6/3/2021
<br />6/3/2022
<br />DAMES Ea occAGE TO RENTED
<br />PREMISurrence
<br />300,000
<br />$
<br />IVIED EXP (Any oneperson)
<br />$ 5,000
<br />PERSONAL & ADV INJURY
<br />$ 1,000,000
<br />GENT
<br />AGGREGATE LIMIT APPLIES PER:
<br />GENERAL AGGREGATE
<br />$ 2,000,000
<br />POLICY X71 PEA LOC
<br />PRODUCTS - COMP/OP AGG
<br />$ 2,000,000
<br />$
<br />OTHER:
<br />B
<br />AUTOMOBILE
<br />LIABILITY
<br />COMBINED SINGLE LIMIT
<br />Ea accident
<br />1,000,000
<br />$
<br />X
<br />BODILY INJURY Perperson)
<br />$
<br />ANY AUTO
<br />8107NO34898
<br />6/3/2021
<br />6/3/2022
<br />OWNED SCHEDULED
<br />AUTOS ONLY AUTOS
<br />BODILY INJURY Per accident
<br />$
<br />X
<br />PROPERTY DAMAGE
<br />Per accident)
<br />ccident
<br />$
<br />HIRED X NON -OWNED
<br />AUTOS ONLY AUTOS ONLY
<br />C
<br />X
<br />UMBRELLA LIAB
<br />X
<br />OCCUR
<br />EACH OCCURRENCE
<br />$ 5,000,000
<br />EXCESS LIAB
<br />CLAIMS -MADE
<br />CUP7N053692
<br />6/3/2021
<br />6/3/2022
<br />AGGREGATE
<br />$ 5,000,000
<br />DED X RETENTION $ 10,000
<br />$
<br />C
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY
<br />Y/N
<br />R/EXECUTIVE ❑
<br />ANY PROPRIETOR/ EXCLUDED?
<br />OF EXCLUDED?
<br />(Mandatory in NH)
<br />N/A A
<br />UB7N03885A
<br />6/3/2021
<br />6/3/2022
<br />X PER R
<br />STATUTE EER
<br />E.L. EACH ACCIDENT
<br />1,000,000
<br />$
<br />E.L. DISEASE - EA EMPLOYEE
<br />$ 1,000,000
<br />If yes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />E.L. DISEASE - POLICY LIMIT
<br />1,000,000
<br />$
<br />D
<br />Professional E&O
<br />LHR843173
<br />6/3/2021
<br />6/3/2022
<br />Ded
<br />5,000,000
<br />E
<br />Worker's Compensatio
<br />DBA6078883296
<br />6/3/2021
<br />6/3/2022
<br />7erCIaim/$10K
<br />efense Base Act Lim
<br />1,000,000
<br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required)
<br />Professional E&O - Claims Made Retro Date: 4-26-2007 ($2,000,000 limit); Professional E&O - Claims Made Retro Date: 6-19-2019 ($5,000,000 Each Claim limit -
<br />$5,000,000 Aggregate Limit) - Network Security & Privacy Limit is $250,000 - $10,000 Per Claim Deductible Applies to Indemnity & Expense.
<br />Certificate holders continued: City of Santa Ana, officers, agents, employees, and volunteers. Additional insured as respects general liability on a primary &
<br />non-contributory basis including a waiver of subrogation per forms CGD414 04-08 and CGD379 02-19 (attached). Additional insured as respects auto liability
<br />including a waiver of subrogation per forms CAT474 08-17 and CAT353 08-17 (attached). Waiver of subrogation on worker's compensation per form WC990376
<br />(attached).
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />City of Santa Ana
<br />Y
<br />THE EXPIRATION DATE THEREOF,
<br />NOTICE WILL 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 />�oRaN
<br />RAManagementDMsian
<br />REVIEWED & APPROPVED BY.-
<br />o z
<br />oI
<br />v�
<br />ACORD 25 (2016/03)
<br />© 1988-2015 ACORD C
<br />'
<br />The ACORD name and logo are registered marks of ACORD
<br />Risk Management Analyst
<br />
|