|
Digitally signed by Frandne 0,
<br />Francine R. Villareal Vnlareal
<br />AC®Rio® CERTIFICATE OF LIABILITY INSURANCE
<br />lk.
<br />DATE(MMIODIYYYY)
<br />04/19/2021
<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 />Basin Pacific Insurance & Benefits
<br />1025 S. Pioneer Way
<br />NAME;C Carlo Narduzzi, Branch Mana in Partner
<br />PHONE
<br />(Ar, N 509 470-6000 Fa"c Ne:509-470-6272
<br />E-MAIL SS, cnarduzzi@basinpacific.com
<br />INSURII AFFORDING COVERAGE
<br />NAIC If
<br />Moses Lake, WA 98837
<br />INSURER A: Valley Fore Insurance Company
<br />20508
<br />INSURED
<br />Airstreams Renewables, Inc.
<br />410 West J Street, Suite A
<br />INSURER : Continental CasualtV
<br />20443
<br />INSURER : Evanston Insurance Con)any
<br />35378
<br />INSURER : State Compensation Insur nce Fund
<br />35076
<br />Tehachapi, CA 93561
<br />INSURER E:
<br />INSURER F :
<br />COVERAGES CERTIFICATE NUMBER: RPWR1nN NiunnaFR•
<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 />ICTR
<br />TYPE OF INSURANCE
<br />ADDL
<br />SUER
<br />POLICYNUMBER
<br />POLICY EFF
<br />MMIDDIYYYY
<br />POLICY EXP
<br />MMIDDNYYY
<br />LIMITS
<br />A
<br />COMMERCIAL GENERAL LIABILITY
<br />CLAIMS -MADE OCCUR
<br />6057171294
<br />05101/2021
<br />05l01l2022
<br />EACH OCCURRENCE
<br />$1,000,000
<br />DAMAGE TO RENTED
<br />PREMISES Eeoccunumce
<br />$ 100,000
<br />MED EXP(Any one Person)
<br />$ 15,000
<br />PERSONAL&ADV INJURY
<br />$ 1,000,000
<br />GEN'L
<br />%(
<br />AGGREGATE LIMIT APPLIES PER:
<br />POLICY E PEA LOC
<br />OTHER:
<br />GENERAL AGGREGATE
<br />$ 2,000,000
<br />PRODUCTS - COMP/OP AGO
<br />$ 2,000,000
<br />$
<br />B
<br />AUTOMOBILE
<br />X
<br />LIABILITY
<br />ANY AUTO
<br />OWNED ASCHEDULED
<br />AUTOS ONLY UTOS
<br />HIRED NON -OWNED
<br />ONLY AUTOS ONLY
<br />6057171702
<br />05/01/2021
<br />05/01/2022
<br />COMBINEDSINGLE LIMIT
<br />$1,000,000
<br />BODI LV INJU RY(Per person)
<br />$
<br />1AUTOS
<br />BODILY INJURY (Per ecddent)
<br />$
<br />PROPERTY DAMAGE
<br />Per accident
<br />$
<br />Medical Payments
<br />1$5,000
<br />C
<br />X
<br />UMBRELLA LIAB
<br />I EXCESS LIAB
<br />OCCUR
<br />CLAIMS -MADE
<br />MKLV5EUL103232
<br />05/01/2021
<br />05101/2022
<br />EACH OCCURRENCE
<br />$5,000,000
<br />AGGREGATE
<br />$ 5,000,000
<br />DEO I I RETENTION$
<br />$
<br />D
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY YIN
<br />ANYPROPRIETORIPARTNERIEXECUTIVE
<br />OFFICERIMEMBEREXCLUDED1
<br />(Mandatory In NH)
<br />If yes, describe under
<br />DE es,OF OPERATIONS below
<br />NIA
<br />9069628-20
<br />08/28/2020
<br />08/28/2021
<br />�/ PER OTH-
<br />X STATUTE ER
<br />E.L. EACH ACCIDENT
<br />$1,000,000
<br />E.L. DISEASE - EA EMPLOYEE
<br />$1,000,000
<br />E.L. DISEASE -POLICY LIMIT
<br />$1,000,000
<br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 401, Additional Remarks Schedule, may be attached if more space is required)
<br />The City of Santa Ana, its officers, employees, agents, volunteers and representatives are included as an Additional Insured.
<br />Such Insurance as is afforded by this policy shall be primary, and any insurance carried by City shall be excess and
<br />noncontributory. Thirty (30) day prior written notice of cancellation will be provided to certificate holder.
<br />City of Santa Ana
<br />Risk Management Division, 4th Floor
<br />20 Civic Center Plaza
<br />Santa Ana, CA 92702
<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
<br />5 ACORD C
<br />ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
<br />IUD/M
<br />,1%skMam*VmneftDMsImt
<br />REVIEWED IsAPPROVM BY:
<br />Risk Management Analyst
<br />
|