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Digitally signed by Francine R. Francine R. Villareal Villareal ACCORD® CERTIFICATE OF LIABILITY INSURANCE uou DATE(MM/°D/YYYY) 12/1 /2021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER M3 Insurance Solutions, Inc. 828 John Nolen Drive WI 53713 CONTACT NAME: Tara Karls PHONE FAX A/C No Ext : 800-272-2443 A/c, No): 608-273-1725 E-MMadison ADDRESS: Tara.Karls@m3ins.com INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: The Travelers Indemnity Compan 25658 INSURED TOTAADM-01 BASIC Benefits, LLC / BASIC Payroll, LLC INSURER B: Travelers Property Casualty of 25674 INSURERC: The Travelers Indemnity Co. of 25682 INSURERD: Ironshore Companies INSURERE: Travelers Indemnity of America 25666 INSURER F : COVERAGES CERTIFICATE NUMBER: 1420510250 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICYNUMBER POLICY EFF MM/DD POLICY EXP MM/DD LIMITS E X COMMERCIAL GENERAL LIABILITY Y H6305A888588TIA20 10/1/2021 10/1/2022 EACH OCCURRENCE $1,000,000 CLAIMS -MADE OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $ 500,000 MED EXP (Any one person) $ 10,000 PERSONAL &ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY ❑PRO ❑ JECT LOC X PRODUCTS - COMP/OP AGG $ 2,000,000 $ OTHER: A AUTOMOBILE LIABILITY BA6N185851 10/1/2021 10/1/2022 COMBINED SINGLE LIMIT Ea accident $1,000,000 X BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY B X UMBRELLALIAB X OCCUR CUP6J097403 10/1/2021 10/1/2022 EACH OCCURRENCE $ 10,000,000 AGGREGATE $ 10,000,000 EXCESS LIAB CLAIMS -MADE DED RETENTION $ $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N UB6J691951 10/1/2021 10/1/2022 X PER OTH- STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? ❑ N/A E.L. DISEASE - EA EMPLOYEE $ 1,000,000 (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 D Professional Liability PE0901502-01 10/1/2021 10/1/2022 Aggregate 2,000,000 B Cyber Liability ZPL31N32133 10/1/2021 10/1/2022 Aggregate 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) Verification of Insurance only. Certificate holder is considered an additional insured with respect to general liability when required by written contract. A 30 Day Notice of Cancellation applies. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Santa Ana ACCORDANCE WITH THE POLICY PROVISIONS. Risk Management Division 20 Civic Center Plaza A THORIZEDREPRESENTATIVE Santa Ana CA 92702 k I Ri kM&T7Ag't'.Ih1erdDMsiun u" cF REVIEWED & APPROVED BY. @ 1988-2015 ACORD C ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD _ _— Risk Management Analyst