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Digital
<br />A� " CERTIFICATE OF
<br />ABILITY INSURANC _
<br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATIO
<br />LTARACT
<br />F
<br />RIGHTS U J#AFA
<br />C
<br />TT OLDER. THIS
<br />CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY
<br />E ,
<br />THE COV
<br />D
<br />B9HE POLICIES
<br />BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE BETWEEN T' E ISSUING INSURER(S),
<br />AUTHORIZED
<br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. m.('PVPa o
<br />IMPORTANT: If the certificate holder is an ADDITIONAL INSURED a policy(ies) must have ADD I Ir ,JAL IN.' IRED provisions or be endorsed.
<br />If SUBROGATION IS WAIVED, subject to the terms and condition
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<br />or�
<br />this certificate does not confer rights to the certificate holder in Ii
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<br />PRODUCER
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<br />NAME:
<br />g ;,�
<br />arlo ar Azzi, ranch Managing artner
<br />Basin Pacific Insurance &Benefits
<br />ONE
<br />'C Ext :
<br />509-,d , 0- .,000
<br />•
<br />1025 S. Pioneer Way
<br />_ADDRESS:
<br />cna'dtl--zi@basinpaci ic.com
<br />Moses Lake, WA 98837
<br />INSURER(S) AFFORDING COVERAGE
<br />NAIC#
<br />INSURERA:
<br />Valley Fore Insurance Company
<br />20508
<br />INSUR ARirstreams Renewables, Inc.
<br />INSURERB:
<br />Continental Casualty
<br />20443
<br />785 Tucker Rd, Suite G-603
<br />INSURERC:
<br />Homesite Insurance Company
<br />17221
<br />INSURERD:
<br />State Compensation Insurance Fund
<br />35076
<br />Tehachapi, CA 93561
<br />INSURER E :
<br />COVERAGES CERTIFICATE NUMBER: 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 />TYPE OF INSURANCE
<br />ADDL
<br />INSD
<br />SUBR
<br />WVD
<br />POLICY NUMBER
<br />POLICY EFF
<br />MM/DD
<br />POLICY EXP
<br />MM/DD
<br />LIMITS
<br />A
<br />COMMERCIAL GENERAL LIABILITY
<br />CLAIMS -MADE � OCCUR
<br />6057171294
<br />05/01/2022
<br />05/01/2023
<br />EACH OCCURRENCE
<br />$ 1 ,000,000
<br />DAMAGE TO RENTED
<br />PREMISES Ea occurrence
<br />$ 100,000
<br />MED EXP (Any one person)
<br />$ 15,000
<br />PERSONAL & ADV INJURY
<br />$ 1,000,000
<br />GEN'L
<br />AGGREGATE LIMIT APPLIES PER:
<br />GENERALAGGREGATE
<br />$ 2,000,000
<br />POLICY ❑ PRO ❑ LOC
<br />JECT
<br />x
<br />PRODUCTS-COMP/OPAGG
<br />$ 2,000,000
<br />$
<br />OTHER:
<br />B
<br />AUTOMOBILE
<br />LIABILITY
<br />6057171702
<br />05/01/2022
<br />05/01/2023
<br />COMBINED SINGLE LIMIT
<br />Ea accident
<br />$1,000,000
<br />X
<br />ANY AUTO
<br />BODILY INJURY (Per person)
<br />$
<br />OWNED SCHEDULED
<br />AUTOS ONLY AUTOS
<br />BODILY INJURY (Per accident)
<br />$
<br />PROPERTY DAMAGE
<br />Per accident
<br />$
<br />HIRED NON -OWNED
<br />AUTOS ONLY AUTOS ONLY
<br />Medical Payments
<br />$ 5,000
<br />C
<br />UMBRELLALIAB
<br />EXCESS LAB
<br />OCCUR
<br />CLAIMS -MADE
<br />CXP- 005213-00
<br />05/01/2022
<br />05/01/2023
<br />EACH OCCURRENCE
<br />$5,000,000
<br />X
<br />AGGREGATE
<br />$ 5,000,000
<br />DED RETENTION $
<br />$
<br />D
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY Y / N
<br />ANYPROPRIETOR/PARTNER/EXECUTIVE
<br />9069628-21
<br />08/28/2021
<br />08/28/2022
<br />PER OTH-
<br />X STATUTE ER
<br />E.L. EACH ACCIDENT
<br />$ 1 ,000,000
<br />OFFICER/MEMBER EXCLUDED? ❑
<br />(Mandatory in NH)
<br />N/A
<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 />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required)
<br />The City of Santa Ana, its officers, officials, employees, agents, volunteers and representatives are included as an Additional
<br />Insured. Such insurance as is afforded and 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 />CERTIFICATE HOLDER CANCELLATION
<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 PROVIS S.
<br />20 Civic Center Plaza
<br />AUTHORIZED REPRESENTATIVE
<br />Santa Ana, CA 92702
<br />Risk ManagementDivisian
<br />+� \@ REVIEWED & RPPRCMED BY:
<br />© 1988-2015 AC
<br />OR
<br />ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD _�_r,__ Risk Management Specialist
<br />
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