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1LOPEZ
<br />Samantha Digitallysignedby
<br />Samantha M. Lambert
<br />M Lambert Date: 2021.09.28 PAULUS ENG
<br />r 11:02:25 -07 00
<br />CERTIFICATE OF LIABILITY INSURANCE
<br />DATFEM/DD1YYYY)(M
<br />/8/2021
<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 />CONTACT
<br />NAME:
<br />PHONE FAX
<br />(A/C, No, Ext): (949) 287-5677 (A/C, No):
<br />THE BROKERAGE COMMERCIAL INSURANCE SERVICES, Inc.
<br />20261 SW Acacia St., Suite 200
<br />Newport Beach, CA 92660
<br />A DD MAIL
<br />INSURERS AFFORDING COVERAGE
<br />NAIC #
<br />INSURERA: Executive Risk Indemnity,Inc.
<br />35181
<br />INSURED
<br />INSURER B:Federal Insurance Company
<br />20281
<br />INSURER C : Travelers Property Casualty Company of America
<br />25674
<br />Paulus Engineering, Inc.
<br />INSURER D :
<br />2871 E. Coronado Street
<br />Anaheim, CA 92806
<br />INSURER E
<br />INSURER F :
<br />COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 2
<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 />MWDD/YYYY
<br />POLICY EXP
<br />MM/DD/YYYY
<br />LIMITS
<br />A
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />EACH OCCURRENCE
<br />$ 1,000,000
<br />CLAIMS -MADE DWI X OCCUR
<br />X
<br />54303105
<br />5/1/2021
<br />5/1/2022
<br />DAMAGE TO RENTED
<br />PREMISES Ea occurrence
<br />100,000
<br />$
<br />MED EXP (Any oneperson)
<br />$ 5,000
<br />PERSONAL & ADV INJURY
<br />$ 1,000,000
<br />GEN'L
<br />AGGREGATE LIMIT APPLIES PER:
<br />GENERAL AGGREGATE
<br />$ 2,000,000
<br />POLICY X JECT El LOC
<br />PRODUCTS - COMP/OPAGG
<br />$ 2,000,000
<br />$
<br />OTHER:
<br />B
<br />AUTOMOBILE
<br />LIABILITY
<br />CMBINED SINGLE LIMIT
<br />EaOaccident
<br />1,000,000
<br />$
<br />X
<br />BODILY INJURY Perperson)
<br />$
<br />ANY AUTO
<br />54303104
<br />5/1/2021
<br />5/1/2022
<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 />C
<br />UMBRELLA LIAB
<br />X
<br />OCCUR
<br />EACH OCCURRENCE
<br />$ 3,000,000
<br />X
<br />EXCESS LIAB
<br />CLAIMS -MADE
<br />ZUP-15T82203-21-NF
<br />5/1/2021
<br />5/1/2022
<br />AGGREGATE
<br />$ 3,000,000
<br />DED X RETENTION $ 10,000
<br />$
<br />B
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY
<br />ANY PROPRIETOR/PARTNER/EXECUTIVE
<br />X
<br />54303106
<br />5/1/2021
<br />5/1/2022
<br />X PER OTH-
<br />STATUTE ER
<br />E.L. EACH ACCIDENT
<br />1,000,000
<br />$
<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 />$
<br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
<br />RE: All operations performed by the Named Insured during the current policy period. glaip/wcwv
<br />City of Santa Ana, its officers, employees, agents, volunteers and representatives are included as Additional Insureds as respects General Liability per
<br />attached endorsement.
<br />This Insurance shall apply as Primary and Non -Contributory per attached endorsement.
<br />Waiver of Subrogation for Workers' Compensation: See Attached Endorsement.
<br />"Excess Liability follows form over the General Liability, Auto Liability, and Employers Liability.
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />City of Santa Ana THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />ty ACCORDANCE WITH THE POLICY PROVISIONS.
<br />20 Civic Center Plaza
<br />Santa Ana, CA 92702
<br />AUTHORIZED REPRESENTATIVE
<br />,„y ortnNC r��l,
<br />.—.•.- --- �' REVIEWED&APPROVED Br
<br />ACORD 25 (2016/03) © 1988-2015 ACORD CII
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<br />The ACORD name and logo are registered marks of ACORD �� Risk Management Supervisor
<br />
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