|
., Tracy o'9na°ys'9"easy Page 1 of 2
<br /> Tracy Jacobs
<br /> A�..:40RV CERTIFICATE OF LIABILITY INSURANCE Jacobs o2,o°Zo, °' DATE(MM//2022Y)
<br /> .. os/o3/2022
<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 CONTACT Willis Towers Watson Certificate Center
<br /> NAME:
<br /> Willis Towers Watson Insurance Services West, Inc.
<br /> c/o 26 Century Blvd PHONE 1-877-945-7378 FAX 1-888-467-2378
<br /> A/C No Ext: A/C,No:
<br /> E-MAIL P.O. Box 305191 ADDRESS: certificates@willis.com
<br /> Nashville, TN 372305191 USA INSURER(S)AFFORDING COVERAGE NAIC#
<br /> INSURERA: National Fire Insurance Company of Hartfor 20478
<br /> INSURED INSURERB: Valley Forge Insurance Company 20508
<br /> IEC Corporation
<br /> 16485 Laguna Canyon Rd #300 INSURERC: Continental Insurance Company 35289
<br /> Irvine, CA 92618 INSURERD: Hartford Fire Insurance Company 19682
<br /> INSURERE: Lloyds Syndicate 2987 C0978
<br /> INSURER F:
<br /> COVERAGES CERTIFICATE NUMBER: W25600572 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS
<br /> LTR INSD WVD POLICY NUMBER MM/DD MM/DD
<br /> x COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
<br /> CLAIMS-MADE � OCCUR DAMAGE TO RENTED 1,000,000
<br /> PREMISES Ea occurrence $
<br /> A MED EXP(Any one person) $ 15,000
<br /> Y 7015251780 07/31/2022 07/31/2023 PERSONAL&ADV INJURY $ 1,000,000
<br /> GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ 2,000,000
<br /> POLICY D PRO-
<br /> JECT LOC PRODUCTS-COMP/OPAGG $ 2,000,000
<br /> OTHER: $
<br /> AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000
<br /> Ea accident
<br /> x ANY AUTO BODILY INJURY(Per person) $
<br /> B OWNED SCHEDULED Y 7015271690 07/31/2022 07/31/2023 BODILY INJURY(Per accident) $
<br /> AUTOS ONLY AUTOS
<br /> HIRED NON-OWNED PROPERTY DAMAGE $
<br /> AUTOS ONLY AUTOS ONLY Per accident
<br /> C
<br /> x UMBRELLALIAB x OCCUR EACH OCCURRENCE $ 15,000,000
<br /> EXCESS LAB CLAIMS-MADE 7015251746 07/31/2022 07/31/2023 AGGREGATE $ 15,000,000
<br /> DED RETENTION$ $
<br /> WORKERS COMPENSATION x PER OTH-
<br /> AND EMPLOYERS'LIABILITY Y/N STATUTE ER
<br /> D ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000
<br /> OFFICE R/M EMBER EXCLUDED? N/A 59 WE AL3MXU 06/01/2022 06/01/2023
<br /> (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000
<br /> If yes,describe under 1,000,000
<br /> DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
<br /> E Student Professional MPL3031022 07/31/2022 07/31/2023 Per Claim $2,000,000
<br /> Liability Per Aggregate $4,000,000
<br /> DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required)
<br /> This Voids and Replaces Previously Issued Certificate Dated 08/02/2022 WITH ID: W25590565.
<br /> The City of Santa Ana and its officers, employees, agents, volunteers, and representatives are included as Additional
<br /> Insureds as respects to General Liability and Auto Liability if required by written contract.
<br /> General Liability and Auto Liability policies shall be Primary and Non-contributory with any other insurance in force
<br /> CERTIFICATE HOLDER CANCELLATION
<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 /> City of Santa Ana
<br /> AUTHORIZED REPRESENTATIVE
<br /> Risk Management Division
<br /> 20 Civic Center Plaza
<br /> Santa Ana, CA 92702 Ride
<br /> REVIEWED&APPROVED Br.
<br /> ©1988-2016 ACORD C( ed.
<br /> ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD
<br /> Risk Management Analyst
<br /> SR ID: 22913564 BATCH: 2619772 [
<br />
|