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Client#: 25320
<br />Francine H. Villareal vina,em
<br />KIMLHORN omeaaziea.oslssoa ores'
<br />ACORD. CERTIFICATE OF LIABILITY INSURANCE
<br />DATE(MM/DDI1'YYY)
<br />4/0112021
<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(les) 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 any rights to the certificate holder In lieu of such endorsement(s).
<br />PRODUCER
<br />NAMEACT Jerry Noyola
<br />Grayling Ins. Brokerage/EPIC
<br />PHONE FUF
<br />3780 Mansell Road, Suite 370
<br />Ext:770.220.7699 Ac Na:
<br />E-MAIL
<br />ADDRESS: jerry.noyola@greyling.com
<br />Alpharetta, GA 30022
<br />INSURER(S) AFFORDING COVERAGE
<br />NAIC #
<br />INSURER A: National Union Fire Ins. Co.
<br />19445
<br />INSURED
<br />INSURER B : Allied World Assurance Company (U.S.)
<br />19489
<br />Kimley-Horn and Associates, Inc.
<br />INSURERC: New Hampshire Ins. Co.
<br />23841
<br />421 Fayetteville Street, Suite 600
<br />INSURER D : Lloyds Of London
<br />085202
<br />Raleigh, INC 27601
<br />INSURER E
<br />INSURER F :
<br />COVERAGES CERTIFICATE NUMBER: 21-22 RFVIRIrTN NIIMRFR•
<br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVEBEEN ISSUED TOTHE INSURED NAMEDABOVE FORTHE POL1 YPERIOD
<br />INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITIONOF ANY CONTRACTOR 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 />LTR
<br />TYPE OF INSURANCE
<br />ADDL
<br />INSR
<br />SUER
<br />WVD
<br />POLICY NUMBER
<br />POLICY EFF
<br />MMIDD/YYYY
<br />POLICY EXP
<br />MMIDDIYYYY
<br />LIMITS
<br />A
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />CLAIMS MADE � OCCUR
<br />GL5268169
<br />D4/01/2021
<br />04/01/202'
<br />EACH
<br />$1,000000
<br />qOCCURRENCE
<br />PREMISESOERENccmranee
<br />$500DDD
<br />X
<br />MED EXP (Any one person)
<br />$25 DDD
<br />Contractual Liab
<br />PERSONAL&ADV INJURY
<br />$1,000,000
<br />GEN'L
<br />AGGREGATE LIMIT APPLIES PER:
<br />POLICY [ X1 JECT LOD
<br />GENERAL AGGREGATE
<br />$2,D00,00D
<br />PRODUCTS-COMP/OP AGG
<br />$2,000,000
<br />$
<br />OTHER:
<br />A
<br />AUTOMOBILE
<br />LIABILITY
<br />CA4489663
<br />4/01/2021
<br />04/01/2022
<br />EaaBINtlEEDiSINGLE LIMIT
<br />$2000,000
<br />X
<br />BODILY INJURY (Per person)
<br />$
<br />ANY AUTO
<br />AUTOS ONLYHAUTOSULED
<br />HIRED ONLY NON -OWNED
<br />AUTOS ONLY
<br />BODILY INJURY (Per accident)
<br />$
<br />X
<br />PROPERTY DAMAGE
<br />Per accident
<br />$
<br />B
<br />X
<br />UMBRELLALIAB
<br />X
<br />OCCUR
<br />03127930
<br />4/01/2021
<br />04/01/2022
<br />EACH OCCURRENCE
<br />$5000000
<br />AGGREGATE
<br />$5 ODD 000
<br />X
<br />EXCESS LIAB
<br />CLAIMS -MADE
<br />DED I X RETENTION$1D000
<br />$
<br />c
<br />A
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY YIN
<br />ANYCERIMEMBEREXCLUDED? CUTIVE(�
<br />OFFICER/MEMBEREXCLUDR/E N
<br />NIA
<br />WC015893685 AOS
<br />( )
<br />WC015893686(CA)
<br />4/01/2021
<br />4/01/2021
<br />04/01/202
<br />04/01/202
<br />X PER OTH-
<br />ATUTE ER
<br />E.L. EACH ACCIDENT
<br />$1,000,000
<br />E.L. DISEASE - EA EMPLOYEEI
<br />$1.000000
<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 />D
<br />Professional Liab
<br />04/01/2021
<br />04/01/202
<br />Per Claim $2,000,000
<br />L-60146LDUSA2104949
<br />Aggregate $2,000,000
<br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached If more space Is required)
<br />Re: City of Santa Ana Agreement - Warner Avenue Protected Bike Lanes PS&E; Othman Elmezain. The City, its
<br />officers, employees, agents, volunteers and representatives are named as Additional Insureds with respects
<br />to General Liability where required by written contract. Separation of Insureds applies to the General
<br />Liability Policy. Should any of the above described policies be cancelled by the issuing insurer before the
<br />expiration date thereof, 30 days' written notice (except 10 days for nonpayment of premium) will be
<br />(See Attached Descriptions)
<br />City of Santa Ana SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />Risk Management Division ACCORDANCE WITH THE POLICY PROVISIONS.
<br />20 Civic Center Plaza, 4th Floor
<br />Santa Ana, CA 92701 AUTHORIZED REPRESENTATIVE
<br />nn ,,,����,,,,pppp ��.� AA�. RteleMmlagtmentDkaLslon
<br />AV.y'4/ " REVIEWED&APPROVED BY:.
<br />9)1988-2015 ACORD I 4 P, V'
<br />ACORD 25 (2016/03) 1 of 2 The ACORD name and logo are registered marks of ACORD IW MarmUnn cat Analyst
<br />#S2680616/M2660308 . ,7. 7 7
<br />
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