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<br />ACoR" CERTIFICATE OF LIABILITY INSURANCE Jacobs 09:073
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<br />�OT�
<br />6/30/20222022
<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 />Marsh Risk & Insurance Services
<br />PHONE FAX
<br />17901 Von Karman Avenue, Suite 1100
<br />A/C No Ext : A/C, No):
<br />E-MAIL
<br />(949) 399-5800, License #0437153
<br />Irvine, CA 92614
<br />ADDRESS:
<br />Attn: NewportBeach.CertRequest@marsh.com/F:212-948-4323
<br />INSURER(S) AFFORDING COVERAGE
<br />NAIC#
<br />INSURERA: Crum & Forster Specialty Insurance Cc
<br />44520
<br />CN115158923-01-01-22-23
<br />INSURED PlaceWorks, Inc
<br />INSURER B: Travelers Property Casualty Co. Of America
<br />25674
<br />INSURER C
<br />3 MacArthur Place, Suite 1100
<br />Santa Ana, CA 92707
<br />INSURER D
<br />INSURER E
<br />INSURER F :
<br />COVERAGES CERTIFICATE NUMBER: LOS-002212046-29 REVISION NUMBER: 12
<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
<br />POLICY EXP
<br />MM/DD
<br />LIMITS
<br />A
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />X
<br />X
<br />EPK140207
<br />07/01/2022
<br />07/01/2023
<br />EACH OCCURRENCE
<br />$ 5,000,000
<br />CLAIMS -MADE 1XI OCCUR
<br />DAMAGE TO RENTED
<br />PREMISES(E. occurrence)
<br />ccurrrence)$
<br />50,000
<br />X
<br />MED EXP (Any one person)
<br />$ 5,000
<br />BI & PD Ded. $5,000
<br />PERSONAL & ADV INJURY
<br />$ 5,000,000
<br />GEN'L
<br />AGGREGATE LIMIT APPLIES PER:
<br />GENERALAGGREGATE
<br />$ 5,000,000
<br />POLICY ❑PRO JECT ❑ LOC
<br />X
<br />PRODUCTS - COMP/OP AGG
<br />$ 5,000,000
<br />Contractors Pollution
<br />$ 5,000,000
<br />OTHER:
<br />B
<br />AUTOMOBILE
<br />LIABILITY
<br />X
<br />X
<br />BA1N96406A2243G
<br />07/01/2022
<br />07/01/2023
<br />COEaMBINED ident SINGLE LIMIT
<br />$ 1,O1,000,000acc
<br />X
<br />BODILY INJURY (Per person)
<br />$
<br />ANY AUTO
<br />OWNED SCHEDULED
<br />AUTOS ONLY AUTOS
<br />BODILY INJURY (Per accident)
<br />$
<br />PROPERTY DAMAGE
<br />Per accident
<br />$
<br />HIRED NON -OWNED
<br />AUTOS ONLY AUTOS ONLY
<br />Comp/Coll Deductibles
<br />$ 1,000
<br />UMBRELLALIAB
<br />X
<br />OCCUR
<br />EX6J3287562243
<br />07/01/2022
<br />07/01/2023
<br />EACH OCCURRENCE
<br />$ 4,000,000
<br />X
<br />AGGREGATE
<br />$ 4,000,000
<br />EXCESS LAB
<br />CLAIMS -MADE
<br />DED RETENTION $
<br />$
<br />B
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY
<br />ANYPROPRIETOR/PARTNER/EXECUTIVE Y / N
<br />OFFICE R/M EMBER EXCLUDED? ❑N
<br />(Mandatory in NH)
<br />N/A
<br />UB7K7286762243G
<br />07/01/2022
<br />07/01/2023
<br />X PER oTH-
<br />STATUTE ER
<br />E.L. EACH ACCIDENT
<br />$ 1,000,000
<br />E.L. DISEASE - EA EMPLOYEE
<br />$ 1,000,000
<br />If yes, describe under
<br />OF OPERATIONS below
<br />E.L. DISEASE - POLICY LIMIT
<br />1,000,000DESCRIPTION
<br />$
<br />A
<br />Errors & Omissions -Claims Made
<br />EPK140207
<br />07/01/2022
<br />07/01/2023
<br />Each Claim/Aggregate
<br />5,000,000
<br />Retro Dates: See 2nd Page
<br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required)
<br />Re: Operations performed by the named insured for the certificate holder
<br />City of Santa Ana, its officers, agents, employees, and volunteers are included as additional insured where required by written contract with respect to General and Auto Liability. This insurance is primary and non-
<br />contributory over any existing insurance and limited to liability arising out of the operations of the named insured and where required by written contract with respect to General Liability. Waiver of subrogation is
<br />applicable where required by written contract with respect to General and Auto Liability.
<br />CERTIFICATE HOLDER CANCELLATION
<br />City of Santa Ana
<br />Risk Management Division
<br />20 Civic Center Plaza, 4th Floor
<br />Santa Ana, CA 92701
<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 />KM
<br />@ 1988-2016 ACORD
<br />ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
<br />m RI@k
<br />REVIEWED ae APPROVED Br
<br />�— Risk Management Analyst
<br />
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