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Digitally signed by Tori Pierson
<br />Tori Pierson Date: 2021.10.12 11:40A9 -07'00'
<br />ACOR 7 0
<br />`IO CERTIFICATE OF LIABILITY INSURANCE
<br />DATE(MM/DD/YYYY)
<br />10/5/2021
<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 />PRODUCER
<br />AssuredPartners Design Professionals Insurance Services, LLC
<br />3697 Mt. Diablo Blvd Suite 230
<br />CA 94549
<br />CONTACT
<br />NAME: Brlttlnl Alberty
<br />PHONE FAX
<br />(A/C, No Ext : A/C, No):
<br />E-MLafayette
<br />ADDRESS: Brittini.Alberty@AssuredPartners.com
<br />INSURER(S) AFFORDING COVERAGE
<br />NAIC #
<br />INSURERA: Continental Insurance Company
<br />35289
<br />License#:6003745
<br />INSURED CANNCOR-02
<br />INSURERB: Valley Forge Insurance Company
<br />20508
<br />Cannon Corporation
<br />1050 Southwood Drive
<br />INsuRERc: Beazley Insurance Company Inc
<br />37540
<br />INSURERD: HARTFORD INSURANCE COMPANY
<br />38288
<br />San Luis Obispo CA 93401
<br />INSURER E :
<br />INSURER F :
<br />COVERAGES CERTIFICATE NUMBER:23760527 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
<br />LTR
<br />TYPE OF INSURANCE
<br />ADDL
<br />INSD
<br />SUBR
<br />WVD
<br />POLICYNUMBER
<br />POLICY EFF
<br />MM/DD
<br />POLICY EXP
<br />MM/DD
<br />LIMITS
<br />B
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />Y
<br />Y
<br />6079204724
<br />9/1/2021
<br />9/1/2022
<br />EACH OCCURRENCE
<br />$1,000,000
<br />CLAIMS -MADE OCCUR
<br />PREMISES DAMAGE TO
<br />PREMISES Ea occurrence)
<br />ccurrence
<br />$ 500,000
<br />X
<br />MED EXP (Any one person)
<br />$ 15,000
<br />Contractual Liab
<br />Included
<br />PERSONAL &ADV INJURY
<br />$ 1,000,000
<br />GEN'L
<br />AGGREGATE LIMIT APPLIES PER:
<br />GENERAL AGGREGATE
<br />$ 2,000,000
<br />POLICY � PRO- � LOC
<br />PRODUCTS - COMP/OP AGG
<br />$ 2,000,000
<br />$
<br />OTHER:
<br />AUTOMOBILE
<br />LIABILITY
<br />COMBINED SINGLE LIMIT
<br />Ea accident
<br />$
<br />BODILY INJURY (Per person)
<br />$
<br />ANY AUTO
<br />OWNED SCHEDULED
<br />AUTOS ONLY AUTOS
<br />BODILY INJURY (Per accident)
<br />$
<br />FIR ER DAMAGE
<br />Per accident
<br />$
<br />HIRED NON -OWNED
<br />AUTOS ONLY AUTOS ONLY
<br />L
<br />$
<br />A
<br />X
<br />UMBRELLALIAB
<br />X
<br />OCCUR
<br />Y
<br />Y
<br />6079210751
<br />9/1/2021
<br />9/1/2022
<br />EACH OCCURRENCE
<br />$9,000,000
<br />AGGREGATE
<br />$ 9,000,000
<br />EXCESS LAB
<br />CLAIMS -MADE
<br />DED X RETENTION $ 1 n nnn
<br />$
<br />D
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY Y / N
<br />Y
<br />57WEAD8G7X
<br />9/1/2021
<br />9/1/2022
<br />X PER OTH-
<br />STATUTEI ER
<br />ANYPROPRIETOR/PARTNER/EXECUTIVE
<br />E.L. EACH ACCIDENT
<br />$ 1,000,000
<br />OFFICER/MEMBER EXCLUDED? ❑
<br />N/A
<br />E.L. DISEASE - EA EMPLOYEE
<br />$ 1,000,000
<br />(Mandatory in NH)
<br />If yes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />E.L. DISEASE - POLICY LIMIT
<br />$ 1,000,000
<br />C
<br />ProfessionalLiability
<br />V27737190101
<br />9/1/2021
<br />9/1/2022
<br />Per Claim
<br />$2,000,000
<br />Annual Aggregate
<br />$2,000,000
<br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required)
<br />Umbrella Liability policy is a follow -form to underlying General Liability/Auto Liability/Employers Liability.
<br />RE: City of Santa Ana on Project #A2019-1174-03 , A-2020-153-03, A-2021-075-03 / Cannon #190815 City of Santa Ana, its officers, employees, agents,
<br />volunteers and representatives are named as an additional insured as respects general liability as required per written contract or agreement. General Liability
<br />are Primary/Non-Contributory per policy form wording. Insurance coverage includes waiver of subrogation per the attached endorsement(s). Certificate of
<br />Insurance shall provide thirty (30) day prior written notice of cancellation
<br />L,r-M I lr'IL A I C MULUCK L AIVI.CLLA I Ivry OU uav Ivouce Of k anceuauon
<br />City of Santa Ana
<br />Attn: 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 RiskMowgemenf Division
<br />HEmEwm & APPROVED B
<br />© 1988-2015 ACORD C( — rus._nage
<br />ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
<br />
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