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Frnnrina R DiaiWivsianed by Francine R.
<br />AC"j?" CERTIFICATE OF LIABILITY INSURANC 'llareal Dacezoz
<br />ozni§lt2T€-0MM1V}
<br />07l15/20212C21
<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 *grown Craig
<br />NAME;
<br />INSURANCE SOURCE INC
<br />PHONE (314) 416-26C0 Fnx (314) 416-1011
<br />AlC, NoLEzt): AfC, No
<br />4111 TELEGRAPH RD. SUITE Zoo
<br />E-MAIL craig@theinsurancesource.ccm
<br />ADDRESS:
<br />INSURER($) AFFORDING COVERAGE
<br />NAIC ff
<br />ST LOUIS MD 63129-2755
<br />INSURERA: ACE Property and Casualty Insurance Company
<br />_
<br />20699C —
<br />INSURED
<br />Chubb Indemnity Ins Cc
<br />INSURER 8: y
<br />12777
<br />Prime Government Solutions, Inc.
<br />_ _
<br />INSURER C : Chubb & Son
<br />10052
<br />912 S. Capital of Texas Highway
<br />INSURER D : —`
<br />INSURER E :
<br />Austin, Texas 78746
<br />INSURER F :
<br />COVERAGES CERTIFICATE NUMBER: UL21 (Ib21411 REVISION NUMBER:
<br />THIS IS TO CERTIFY THATTHE 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 MAYBE 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 />R AD DC SUER I POLICYEFF POLICY EXP — R TYPE OF INSURANCE INSD yip POLICY NUMBER — fM10 MDlYYYYj-_ (MMIDDfYYYY) LIMITS _
<br />7___7IMERCIAL GENERAL LIABILITY EACH OCCURRENCE T _— $ 1.000.000
<br />� [7AMAGF- T LN 1-1 300000
<br />CLAIMS -MADE L"1 C)CCUIl PRFMI$FS (Ea occurrence).— 5 —
<br />A Y Y PHFD94974112 003
<br />GrN'I_AGGREGATE LIMITAPPLIES PER:
<br />POI Icy PRO- __...
<br />i< SOdeductible — ---- — -- - —
<br />AUTOMOBILE LIABILITY
<br />_- ANY AUTO
<br />q awNED SCHEDULED PHFD94974112 003
<br />_ AUTOS ONLY AU10S
<br />_X, AUIEOSONI_Y I/� ALFOSCALY
<br />x UMBRELLA LIAR 1 OCCUR
<br />A EXCESS LIAR _LtCLAIMS-MADE Y Y UMBTXD948111323N
<br />❑Fl)_._,1.,/'\ RETt_N110N 5
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY YIN
<br />R ANY PROPRIF 1CRIPART NERIFX{-CUTIVU NIA Y 71778180
<br />OFf-IC1-RIM Ei_ oER EXCLum-6, I J
<br />(Mandatary in Nti)
<br />If yea, tioscribe under
<br />O6SCRIf'110N OF OPERATIONS below
<br />Professional and Cyber Liability T]
<br />C D94366458
<br />_MED EXP (Any one person) 5 `5,000
<br />05115/2021 05/15/2022 _ 1,000,000
<br />PERSONAL &ADV INJURY _ 5 _ _
<br />GENT-RALAGGRFGATL- 5 2,000,000
<br />PRODUCTS - COMPIOPAGG 5�2,000,000
<br />COMBINED SINGLE LIMII
<br />S 1,000,000
<br />BODILY INJURY (Per porson)
<br />5
<br />D511512021
<br />05/15/2022
<br />F30DILY INJURY (Pcr accidenl}
<br />S
<br />PROPERTY DAMAC3F
<br />(Per accident
<br />5
<br />—
<br />—
<br />EACI I OCCURRENCI=-------
<br />S 2,000,000 -----
<br />AGGREGATE
<br />5 2, 000 , 000
<br />05115/2021
<br />05/ 15/2022
<br />05/15/2021 05/15/2022 E L. EACH ACCIDENT — _ 5 1,000,000
<br />E.L. OISFASE - EA EMPLOYEE S 1,000,000
<br />E.L.DISFASE- POLICY LIMIT $ 1.000,a00
<br />0910112020 1 05 / 1512022
<br />DESCRIPTION OF OPERATIONS f LOCATIONS f VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required)
<br />The City of Santa, it's officers, officials, employees, and volunteers are to be covered as additional insureds on the CGL policy with respect to liability arising
<br />out of work or operations performed by or on behalf of the Contracotr including materials, parts or equipment furnished in connection with suck work or
<br />operations. This coverage is primary and non-contrubutory at least as broad as 130 CG 20 10 11 85 as respects the Entity, it's officers, officials, employees
<br />or volunteers . Any insurance or self insurance maintained by the Entity, it's officers, officials, employees or volunteers shall be excess of the Contractors
<br />insurance and shall not contribute with it This CGL policy and workers compensation policy offer the Entity a waiver of subrogation
<br />CERTIFICATE HOLDER CANCELLATION
<br />$5,000,000
<br />$0 deductible
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />City of Santa Ana Risk Management Division ACCORDANCE WI THE POLICY PROVISIONS.
<br />20 Civic Center Plaza AUTHORIZED R RES 'ATIV
<br />Santa Ana CA 92702
<br />�on.H Risk ManagcrnadDiMiaion
<br />©1988-2015ACORD % x REVIEWED&APPROVEDBY.
<br />ACORD 25 (2016103) The ACORD name and logo are registered a i of ACORD
<br />— Risk Management Analyst
<br />
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