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Samantha A Digitally signed by SamanthaM.
<br />I Lambert
<br />LamhPrt Date: 2021.10.0511-11-03-07'00'
<br />,a`oizo° CERTIFICATE OF LIABILITY INSURANCE
<br />DATEDDIYYYY)
<br />E (MM/ DN
<br />021
<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 />RBN Insurance Services
<br />303 E Wacker Dr Ste 650
<br />Chicago IL 60601
<br />CONTACT
<br />NAME: Symone White
<br />PHONE FAX
<br />HONE
<br />No Ext : 312-856-9400 A/c, No : 312-856-9425
<br />ADDRESS: swhite@rbninsurance.com
<br />INSURER(S) AFFORDING COVERAGE
<br />NAIC #
<br />INSURER A: Hartford Fire Insurance Co.
<br />19682
<br />INSURED SAFELLC-01
<br />Intelwest Consulting Group
<br />P.O. Box 18330
<br />INSURER B : Hartford Casualty Insurance Co
<br />29424
<br />INSURER C : Great American E&S Ins. Co.
<br />37532
<br />INSURER D : Twin City Fire Insurance Co.
<br />29459
<br />Boulder CO 80308
<br />INSURER E: Bridgeway Insurance Company
<br />12489
<br />INSURER F : Navigators Specialty Ins. Co.
<br />36056
<br />COVERAGES CERTIFICATE NUMBER: 1135316927 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 />OF INSURANCE
<br />ADDLTYPE
<br />INSD
<br />WVDUBR
<br />POLICY NUMBER
<br />MM DDPOLICY
<br />IYYYYI
<br />iMM/DDfYYYYI
<br />LIMITS
<br />A
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />Y
<br />Y
<br />83UENZV3951
<br />10/3/2021
<br />10/3/2022
<br />EACH OCCURRENCE
<br />$ 1,000,000
<br />CLAIMS -MADE OCCUR
<br />DAMAGE TO RENTED
<br />PREMISES Ea occurrence
<br />$ 300, 000
<br />MED EXP (Any one person)
<br />$ 10,000
<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 ❑
<br />JECT LOC
<br />X
<br />PRODUCTS - COMP/OP AGG
<br />$ 2,000,000
<br />$
<br />OTHER:
<br />B
<br />AUTOMOBILE LIABILITY
<br />Y
<br />Y
<br />83UENPY9100
<br />10/3/2021
<br />10/3/2022
<br />COMBINED SINGLE LIMIT
<br />Ea accident
<br />$ 1,000,000
<br />BODILY INJURY (Per person)
<br />$
<br />X ANY AUTO
<br />OWNED SCHEDULED
<br />AUTOS ONLY AUTOS
<br />BODILY INJURY (Per accident)
<br />$
<br />PROPERTY DAMAGE
<br />Per accident
<br />$
<br />X HIRED X NON -OWNED
<br />AUTOS ONLY AUTOS ONLY
<br />F
<br />UMBRELLALIAB
<br />X
<br />OCCUR
<br />CH21EXC8856001C
<br />10/3/2021
<br />10/3/2022
<br />EACH OCCURRENCE
<br />$5,000,000
<br />X
<br />AGGREGATE
<br />$5,000,000
<br />EXCESS LIAB
<br />CLAIMS -MADE
<br />DED X RETENTION $,
<br />$
<br />D
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY YIN
<br />ANYPROPRIETOR/PARTNER/EXECUTIVE
<br />Y
<br />83WEGE0623
<br />5/12/2021
<br />5/12/2022
<br />X PER OTH-
<br />STATUTE ER
<br />E.L. EACH ACCIDENT
<br />$ 1,000,000
<br />OFFICER/MEMBER EXCLUDED?
<br />NIA
<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 />Professional Liability
<br />TER 2861558
<br />10/3/2021
<br />10/3/2022
<br />Each Claim/Aggregate
<br />10,000,000
<br />E
<br />Excess Liab (2nd) Layer
<br />SE-A7-XL-0002079-00
<br />10/3/2021
<br />10/3/2022
<br />Each Occ/Aggregate
<br />5,000,000
<br />DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
<br />The City of Santa Ana, its officers, employees, agents and representatives are Additional Insured on a primary and non-contributory basis as respects the
<br />General Liability and Auto Liability as required by written contract. A Waiver of Subrogation applies in favor of the Additional Insured as respects the General
<br />Liability, Auto Liability, and Workers Compensation as required by written contract. 30 Days Notice of Cancellation applies. 10 Days Notice for Non -Payment of
<br />premium applies.
<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 />City of Santa Ana ACCORDANCE WITH THE POLICY PROVISIONS.
<br />Risk Management Division
<br />20 Civic Center Plaza AUTHORIZED REPRESENTATIVE
<br />Santa Ana CA 92702
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<br />REviEWED & APPROVED Br
<br />@ 1988-2015 ACORD C
<br />5-"�
<br />ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
<br />�� Risk Management Supervisor
<br />
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