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Francine R. Digital I signed by Francine R.
<br />Villareal
<br />Villareal Date: 2021.09.24144021-07'00'
<br />/
<br />A� " CERTIFICATE OF LIABILITY INSURANCE
<br />ATE (MM/DDYYY)
<br />/Y9/20/2021
<br />r
<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 Patriot Risk & Insurance Services
<br />NAMEACT
<br />2415 Campus Drive, Suite #200
<br />Irvine, CA 92612
<br />PHONEFAX
<br />Ext: 949 486-7900 ,No
<br />E-MAIL
<br />Al
<br />INSURER(S) AFFORDING COVERAGE
<br />NAIC #
<br />INSURERA: Middlesex Insurance Company
<br />23434
<br />www.patrisk.com OK07568
<br />INSURED
<br />Mike Prlich & Sons, Inc.
<br />5103 Elton St.
<br />INSURER B : Great American Insurance Company
<br />16691
<br />INSURERC: State Compensation Insurance Fund
<br />INSURERD: Ironshore Specialty Insurance Co
<br />25445
<br />Baldwin Park CA 91706
<br />INSURER E : Lloyds of London
<br />INSURER F :
<br />COVERAGES CERTIFICATE NUMBER: 64000711 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 />POLICYNUMBER
<br />POLICY EFF
<br />MM/DD
<br />POLICY EXP
<br />MM/DD
<br />LIMITS
<br />A
<br />/
<br />COMMERCIAL GENERAL LIABILITY
<br />A0152818
<br />8/1/2021
<br />8/1/2022
<br />EACH OCCURRENCE
<br />$1,000,000
<br />CLAIMS -MADE Iv] OCCUR
<br />PREM SESOEa occurrDence
<br />$ 500,000
<br />V
<br />MED EXP (Any one person)
<br />$ 10,000
<br />$5,000 Deductible
<br />PERSONAL & ADV INJURY
<br />$ 1 ,000,000
<br />GEN'L
<br />AGGREGATE LIMIT APPLIES PER:
<br />GENERALAGGREGATE
<br />$3,000,000
<br />PRO -
<br />POLICY ✓� ECT LOC
<br />PRODUCTS - COMP/OP AGG
<br />$ 2,000,000
<br />1�
<br />$
<br />OTHER:
<br />A
<br />AUTOMOBILE
<br />LIABILITY
<br />A0152818
<br />8/1/2021
<br />8/1/2022
<br />aBINEDtSINGLE LIMIT
<br />(Ea
<br />$ 1,000,000
<br />BODILY INJURY (Per person)
<br />$
<br />ANY AUTO
<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 />B
<br />UMBRELLA LAB
<br />�/
<br />OCCUR
<br />TUE405237300
<br />8/1/2021
<br />8/1/2022
<br />EACH OCCURRENCE
<br />$10,000,000
<br />AGGREGATE
<br />$ 10,000,000
<br />EXCESS LAB
<br />CLAIMS -MADE
<br />DED RETENTION $
<br />$
<br />C
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY Y / N
<br />OFFICER/MEMBER EXCLUDED? ECUTIVE ❑N
<br />N /A
<br />9280970-2021
<br />8/1/2021
<br />8/1/2022
<br />�/ STATUTE OERH
<br />E.L. EACH ACCIDENT
<br />$ 1,000,000
<br />E.L. DISEASE - EA EMPLOYEE
<br />$ 1 000 000
<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 />Pollution Liability
<br />ICELLUW00112587
<br />8/1/2021
<br />8/1/2022
<br />$2,000,000 Occur / $2,000,000 Aggregate
<br />$10,000 Deductible.
<br />E
<br />Professional Liability
<br />ELOO-98-0075-2021
<br />8/1/2021
<br />8/1/2022
<br />$2,000,000 Occurrence/Aggregate
<br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required)
<br />City of Santa Ana, officers, agents, employees, and volunteers are named as additionally insured as respects General Liability per endorsement
<br />attached. Primary/non-contributory endorsement attached. Waiver of subro as respects WC attached.
<br />Excess Liability dec page attached showing the GL in the schedule of underlying
<br />30-day notice of cancellation / 10-days for non-payment of premium.
<br />CERTIFICATE HOLDER CANCELLATION
<br />City Santa Ana
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />of
<br />THE EXPIRATION DATE THEREOF,
<br />NOTICE WILL
<br />BE DELIVERED IN
<br />Risk Management Division
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />20 Civic Center Plaza
<br />Santa Ana CA 92702
<br />AUTHORIZED REPRESENTATIVE s�
<br />�
<br />oRaN
<br />RAManagementDiviainn
<br />Dave Jacobson
<br />REVIEWED & APPROVED BY.-
<br />© 1988-2015 ACORD C
<br />z
<br />ACORD 25 (2016103)
<br />The ACORD name and logo are registered marks of ACORD
<br />Risk Management Analyst
<br />64000711 1 21/22 GL/AU/UMB/WC/POLL I Tina Kennedy 19/20/2021 1:59:50 PM (PDT) I Page 1 of 8
<br />This certificate cancels and supersedes ALL previously issued certificates.
<br />
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