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Client#: 1646435 <br />�F Dlgllal1111gneJol.nalneR. <br />ORRICHER rancine R. Villareal vllla,eal <br />Date! 202102.2516s8 m 06'ee' <br />ACORD,. CERTIFICATE OF LIABILITY INSURANCE <br />DATE(MMIDDIYYYY) <br />2116/2021 <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(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 any rights to the certificate holder in lieu of such endorsement(s). <br />PRODUCER <br />CONTACT <br />NAME: Marifi Bautista <br />US] Insurance Services, LLC <br />2201.9054 <br />201 Mission St 11th FI <br />AHO No Ezt ; AIC, No <br />noDalEss: marifi.bautista@usi.com <br />San Francisco, CA 94105 <br />628 201-9001 <br />INSURER(3)AFFORDING COVERAGE <br />NAICq <br />INSURER A: Great Northern Insurance Company <br />20303 <br />INSURED BLX Group, LLC <br />INSURER B : Federal Insurance Company <br />20281 <br />INSURER C: <br />777 South Figueroa Street, Suite 3200 <br />Los Angeles, CA 90017 <br />INSURER D: <br />INSURER E: <br />INSURER F: <br />COVERAGES CEKIIFICATE 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 CONTRACTOR 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 />LTR <br />TYPE OF INSURANCE <br />ADDLSUB <br />INSR <br />WVD <br />POLICYNUMBER <br />POLICY EFF <br />MMIDDIYYYY) <br />POLICY EXP <br />(NIWDDNYYYl <br />LIMITS <br />A <br />X' <br />COMMERCIAL GENERAL LIABILITY <br />CLAIMS -MADE � OCCUR <br />36821161 <br />6101/202006/01/2021EEAACCHq�OECTCURRRENCE <br />$1000000 <br />PREMISES E -Ic ,rence <br />$1,000 QQQ <br />X <br />MED EXP (Any one person) <br />$10000 <br />Host Liquor Included <br />Ind. Contractors <br />PERSONAL &ADV INJURY <br />$1 000,000 <br />X <br />AGGREGATE LI MIT APPLIES P ER: <br />POLICY ❑ JECOT LOD <br />GENERAL AGGREGATE <br />$2,000,000 <br />GEN'L <br />X <br />PRODUCTS - COMP/CPAGO <br />$incl Gen Ag <br />OTHER: <br />$ <br />B <br />AUTOMOBILE <br />LIABILITY <br />7499666E <br />6/01/2020 <br />06/01/2021 <br />COMBINED SINGLE LIMIT <br />Ea accident <br />$1,000,000 <br />BODILY INJURY (Per parson) <br />$ <br />ANY AUTO <br />X <br />OWNED SCHEULED <br />AUTOS ONLY ACT <br />ATED NLV X NON -OWNED <br />AUTOS ONLY <br />BODILY INJURY(Pef accident) <br />$ <br />PROPERTYDAMAGE <br />Per accldont <br />$ <br />B <br />X <br />UMBRELLA LIAR <br />X <br />OCCUR <br />79820023 <br />6/01/2020 <br />06/01/2021 <br />EACH OCCURRENCE <br />$5, 000,000 <br />EXCESS LIAB <br />CLAIMS -MADE <br />AGGREGATE <br />$6,000 OOO <br />DED RETENTION $ <br />$ <br />WORKERS COMPENSATION <br />AND EMPLOYERS' LIABILITY <br />ANY PROPRIETOWPARTNERIEXECUTIVE YIN <br />CFFICERIMEMBER EXCLUDED? <br />NIA <br />PER OTH- <br />E.L EACH ACCIDENT <br />$ <br />E.L. DISEASE - EA EMPLOYEE <br />$ <br />(Mandatory In NH) <br />If yes, describe under <br />E.L. DISEASE -POLICY LIMIT <br />$ <br />DESCRIPTION OF OPERATIONS below <br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached If more space Is required) <br />City of Santa Ana, officers, agents, employees, and volunteers are named as additional insured as relates <br />to general liability and auto liability in accordance with the terms and condition of the policies. The <br />general liability policy is primary and non-contributory when required by written contract. Certificate <br />holder is provided 30 day notice of cancellation and 10 days for non-payment in accordance with the terms <br />and conditions of the policy. <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 />@'1908-2016 ACORD C <br />ACORD 26 (2016103) 1 of 1 The ACORD name and logo are registered marks of ACORD <br />#S31171932/M30483311 <br />,.� Risk Mongement Divislon <br />+73, i REVIEWED&APPROVED BY: <br />I <br />Rek Management Analyst <br />•,4ai�>ui'.£#}".'a Ha{y h#.y.�LYv,:A', fir; '::° <br />