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<br />DATE (MM/DD/YYYY)
<br />CERTIFICATE OF LIABILITY INSURANCE
<br />12/08/2021
<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 />CONTACT
<br />PRODUCER Rose Tonn
<br />NAME:
<br />FAX
<br />PHONE
<br />North Risk Partners(763) 536-8006
<br />(A/C, No):
<br />(A/C, No, Ext):
<br />E-MAIL
<br />P.O. Box 64016rose.tonn@northriskpartners.com
<br />ADDRESS:
<br />INSURER(S) AFFORDING COVERAGENAIC #
<br />St PaulMN55164-0016Great Northern Insurance Company20303
<br />INSURER A :
<br />INSURED Federal Insurance Company20281
<br />INSURER B :
<br />CliftonLarsonAllen LLPChubb Indemnity Insurance Company12777
<br />INSURER C :
<br />LarsonAllen LLP, Clifton Gunderson LLP
<br />INSURER D :
<br />220 South 6th Street, Suite 300
<br />INSURER E :
<br />MinneapolisMN55402-1436
<br />INSURER F :
<br />21/22 CERT #3
<br />COVERAGESCERTIFICATE 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 />ADDLSUBR
<br />INSRPOLICY EFFPOLICY EXP
<br />TYPE OF INSURANCELIMITS
<br />POLICY NUMBER
<br />LTR(MM/DD/YYYY)(MM/DD/YYYY)
<br />INSDWVD
<br />COMMERCIAL GENERAL LIABILITY 1,000,000
<br />EACH OCCURRENCE$
<br />DAMAGE TO RENTED
<br />1,000,000
<br />CLAIMS-MADEOCCUR$
<br />PREMISES (Ea occurrence)
<br />10,000
<br />MED EXP (Any one person)$
<br />A3598356912/31/202112/31/20221,000,000
<br />PERSONAL & ADV INJURY$
<br />2,000,000
<br />GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE$
<br />PRO-
<br />2,000,000
<br />POLICYLOCPRODUCTS - COMP/OP AGG$
<br />JECT
<br />Combined Total10,000,000
<br />$
<br />OTHER:
<br />Aggregate
<br />COMBINED SINGLE LIMIT
<br />AUTOMOBILE LIABILITY 1,000,000
<br />$
<br />(Ea accident)
<br />ANY AUTOBODILY INJURY (Per person)$
<br />OWNEDSCHEDULED
<br />B7357282512/31/202112/31/2022
<br />BODILY INJURY (Per accident)$
<br />AUTOS ONLYAUTOS
<br />HIREDNON-OWNEDPROPERTY DAMAGE
<br />$
<br />(Per accident)
<br />AUTOS ONLYAUTOS ONLY
<br />Uninsured motorist1,000,000
<br />$
<br />combined single limit
<br />UMBRELLA LIAB 50,000,000
<br />OCCUREACH OCCURRENCE$
<br />B EXCESS LIAB 7988074712/31/202112/31/202250,000,000
<br />CLAIMS-MADEAGGREGATE$
<br />0
<br />DEDRETENTION$$
<br />PEROTH-
<br />WORKERS COMPENSATION
<br />STATUTEER
<br />AND EMPLOYERS' LIABILITY
<br />Y / N
<br />1,000,000
<br />ANY PROPRIETOR/PARTNER/EXECUTIVE
<br />E.L. EACH ACCIDENT$
<br />CN N / A 7174927612/31/202112/31/2022
<br />OFFICER/MEMBER EXCLUDED?
<br />1,000,000
<br />(Mandatory in NH)
<br />E.L. DISEASE - EA EMPLOYEE$
<br />If yes, describe under
<br />1,000,000
<br />DESCRIPTION OF OPERATIONS belowE.L. DISEASE - POLICY LIMIT$
<br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
<br />The City, its officers, employees, agents, volunteers and representatives are included as additional insureds on General Liability per form 80-02-2367 Rev
<br />5-07 and on Automobile per form 16-02-0292 Ed 4-11 when required in prior written contract. General Liability is primary and non-contributory per form
<br />80-02-2367 Rev 5-07 and Auto Liability is primary per form 16-02-0292 Ed 4-11 when required in prior written contract. Waiver of Subrogation included on
<br />General Liability per form 80-02-2000 & on Auto per form 16-02-0292 when required in prior written contract. General Liability & Auto Policies have been
<br />endorsed to provide 30 days notice of cancellation, with the exception of 10 days notice of cancellation for non-payment of premium per form 80-02-9779
<br />and 16-02-0306 respectively. Umbrella Policy is follow form. Waiver of Subrogation is included on Workers' Compensation Policies for all states except
<br />Kentucky where prohibited by law utilizing the following policy forms: California WC 99 03 04, Texas WC 42 03 04, All Other States, Except Kentucky WC
<br />CERTIFICATE HOLDERCANCELLATION
<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 />Risk Management Division
<br />AUTHORIZED REPRESENTATIVE
<br />20 Civic Center Plaza, 4th Fl
<br />Santa AnaCA92701
<br />© 1988-2015 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2016/03)The ACORD name and logo are registered marks of ACORD
<br />
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