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Francine R.
<br />Villareal
<br />Digitally signed by Francine
<br />R. Villareal
<br />Date: 2021.10.05 12:29:45
<br />-07'00'
<br />� ®
<br />�`� o CERTIFICATE OF LIABILITY INSURANCE
<br />DATE(MM/DD/YYYY)
<br />09/14/2021
<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. If
<br />SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this
<br />certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
<br />PRODUCER
<br />Aon Risk services Central, Inc.
<br />Omaha NE Office
<br />CONTACT
<br />NAME:
<br />(A/CN No.Ext): (402) 697-1400 A/C No : (402) 697-0017
<br />E-MAIL
<br />ADDRESS:
<br />17807 Burke street
<br />suite 401
<br />Omaha NE 68118 USA
<br />INSURER(S) AFFORDING COVERAGE
<br />NAIC #
<br />INSURED
<br />INSURER A: sentry Insurance Company
<br />24988
<br />Musco sports Lighting, LLC
<br />c/o Musco Corporation
<br />100 1st Ave W
<br />INSURER B: Sentry Casualty Company
<br />28460
<br />INSURERC: Travelers Property Cas Co of America
<br />25674
<br />Oskaloosa IA 52577 USA
<br />INSURERD: Indian Harbor Insurance Company
<br />36940
<br />INSURER E:
<br />INSURER F:
<br />COVERAGES CERTIFICATE NUMBER: 570089135831 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. Limits shown are as requested
<br />LTR
<br />TYPE OF INSURANCE
<br />I N S DI
<br />WVD
<br />I POLICY NUMBER
<br />MM/DD/YYYY
<br />MM/DD/YYYY
<br />LIMITS
<br />A
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />EACH OCCURRENCE
<br />$1, 000, 000
<br />CLAIMS -MADE X❑ OCCUR
<br />PREMISES Ea occurrence)$300,
<br />000
<br />MED EXP (Any one person)
<br />$10 , 000
<br />PERSONAL& ADV INJURY
<br />$1, 000, 000
<br />GEN'LAGGREGATE LIMIT APPLIES PER:
<br />GENERAL AGGREGATE
<br />$2,000,000
<br />POLICY x PRO El LOC
<br />JECT
<br />PRODUCTS - COMP/OP AGG
<br />$2,000,000
<br />OTHER:
<br />A
<br />AUTOMOBILE LIABILITY
<br />90-16877-003
<br />07/01/2021
<br />07/01/2022
<br />COMBINED SINGLE LIMIT
<br />Ea accident
<br />$1, 000, 000
<br />BODILY INJURY ( Per person)
<br />ANY AUTO
<br />XHI
<br />BODILY INJURY (Per accident)
<br />OWNED SCHEDULED
<br />AUTOS ONLY AUTOS
<br />RED AUTOS IX NON -OWNED
<br />X
<br />PROPERTY DAMAGE
<br />Per accident
<br />ONLY AUTOS ONLY
<br />C
<br />X
<br />UMBRELLALIAB
<br />X
<br />OCCUR
<br />CUP3s63336021NF
<br />07101120210710112022
<br />EACH OCCURRENCE
<br />$10,000,000
<br />EXCESS LIAB
<br />CLAIMS -MADE
<br />AGGREGATE
<br />$10, 000, 000
<br />DED I X RETENTION $10, 000
<br />B
<br />WORKERS COMPENSATION AND
<br />9016877001
<br />07101120210710112022
<br />X PER STATUTE OTH-
<br />EREMPLOYERS'
<br />LIABILITY Y/ N
<br />ADS
<br />E.L. EACH ACCIDENT
<br />$1, 000 , 000
<br />B
<br />ANY PROPRIETOR / PARTNER, EXECUTIVE
<br />9016877002
<br />07/01/2021
<br />07/01/2022
<br />OFFICER/MEMBER EXCLUDED?
<br />(Mandatory in NH)
<br />N/A
<br />AZ, WI
<br />E.L. DISEASE -EA EMPLOYEE
<br />$1, 000, 000
<br />If yes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />E.L. DISEASE -POLICY LIMIT
<br />$1, 000, 000
<br />D
<br />Archit&Eng Prof
<br />CEo742113901
<br />07/01/2021
<br />07/01/2022
<br />Aggregate
<br />$5,000,000
<br />Claims -Made
<br />SIR
<br />$250,000
<br />SIR applies per policy terns
<br />& condi
<br />ions
<br />Each Claim
<br />$5,000,000
<br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
<br />RE: Musco Project 211811- Delhi Park Mini -Pitch. City of Santa Ana and U.S. soccer Foundation are included as Additional
<br />Insured in accordance with the policy provisions of the General Liability policy. General Liability policy evidenced herein is
<br />Primary and Non -Contributory to other insurance available to Additional Insured, but only in accordance with the policy's
<br />provisions. A Waiver of subrogation is granted in favor of Certificate Holder in accordance with the policy provisions of the
<br />General Liability, Automobile Liability and Workers' Compensation policies.
<br />c+�
<br />M
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<br />0
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<br />I-
<br />CERTIFICATE HOLDER CANCELLATION 5<
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
<br />EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE
<br />POLICY PROVISIONS.
<br />City of Santa Ana AUTHORIZED REPRESENTATIVE
<br />Risk Management Division
<br />20 Civic Center Plaza -�
<br />Santa Ana CA 92702 USA
<br />�„ortaNc RAMwagementDMsian
<br />©1988-2015 ACORD CO 3 z R�ED &APPROVED BY.-
<br />ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
<br />Risk Management Analyst
<br />
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