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Francine R. Villareal., ..M,anmaY ra„n,ea
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<br />TEROBERT-0 KSHIPPEY
<br />A�ORO CERTIFICATE OF LIABILITY INSURANCE
<br />DATE (MMIDDmvr)
<br />1211s1zozo
<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 endorsemen s).
<br />PRODUCER License#0757776
<br />Newport Beach, CA - HUB International Insurance Services Inc.
<br />4695 MacArthur Court
<br />Suite 600
<br />Newport Beach, CA 92660
<br />NQMeCT Kimberly Shippey
<br />PHONE FAX
<br />(AIC, No, Ezt): (A/C, No):
<br />AEb IE . kimberly.shippey@hubinternational.com
<br />INSURER S AFFORDING COVERAGE
<br />NAICB
<br />INSURER A: Executive Risk Indemnity
<br />35181
<br />INSURED
<br />INSURERS: Federal Insurance Company
<br />20281
<br />INSURER c: Travelers Property Casualty Company of America
<br />25674
<br />T.E. Roberts, Inc.
<br />306 W. Katella Ave Unit B
<br />Orange, CA 92867
<br />INSURER D:
<br />INSURER E :
<br />INSURER F :
<br />COVERAGES CERTIFICATE NUMBER: REVISION N • 01
<br />UMBER.
<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 />TJJIL N—SR-
<br />OF INSURANCE
<br />ADID-LTYPE
<br />KM
<br />SUER
<br />POLICY NUMBER
<br />POLICY EFF
<br />POLICY EXP
<br />LIMITS
<br />A
<br />X
<br />COMMERCIALGENERALLIABILITY
<br />CLAIMS -MADE [X] OCCUR
<br />X
<br />54310281
<br />9/112020
<br />911/2021
<br />EACH OCCURRENCE
<br />$ 1,000,000
<br />DAMAGE TO RENTEDPREMOES (E. Ce
<br />100,000
<br />MED EXP fAry one rson
<br />5,000
<br />PERSONAL&ADV INJURY
<br />1,000,000
<br />GEN'L
<br />AGGREGATE LIMIT APPLIES PER:
<br />POLICY JE0 LOG
<br />GENERAL AGGREGATE
<br />2,000,000
<br />PRODUCTS-COMP/OP AGO
<br />2,000,000
<br />OTHER:
<br />B
<br />AUTOMOBILE
<br />LIABILITY
<br />ANY AUTO
<br />OWNED SCHEDULED
<br />AUTOS ONLY AUTOS p
<br />AUTOS ONLY AUTOS O V
<br />X
<br />54310280
<br />9/112020
<br />9/112021
<br />CO aBINED SINGLE LIMIT cident)$
<br />(EaX
<br />BODILY INJURY Perperson)
<br />1,000,000
<br />$
<br />BODILY INJURY Per accident
<br />$
<br />PerOPLR eel AAIAGE
<br />$
<br />C
<br />X
<br />UMBRELLA LIAB
<br />EXCESS LIAR
<br />X
<br />OCCUR
<br />CLAIMS -MADE
<br />ZUP-91N03112-20-NF
<br />9/112020
<br />9/1/2021
<br />EACH OCCURRENCE
<br />$ 10,000,000
<br />AGGREGATE
<br />$ 1010001000
<br />DED I X I RETENTION$ 10,000
<br />B
<br />WORKERS
<br />ND EMPLOYERS LIABILIITY YIN
<br />ANY PROPRIETORJPARTNERIEXECUTIVE
<br />(Man aRrlr InN )EXCLUDED?
<br />(ManOFFIdatory In NH)
<br />describe under
<br />(DESCRIPTION OF OPERATIONS below
<br />NIA
<br />5431 O2B2
<br />911/2020
<br />911/2021
<br />X STAR FIR
<br />E.L.EACH ACCIDENT
<br />$ 1,000,000
<br />E.L. DISEASE - EA EMPLOYE
<br />$ 1,000,000
<br />E.L. DISEASE - POLICY LIMIT
<br />$ 1,000,000
<br />_T
<br />DESCRIPTION OF OPERATIONS I LOCATIONS VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required)
<br />Re: RFP No. 20-106 - Emergency On -Call Construction Asphalt Concrete, Concrete and Storm Drain Repair Services
<br />City of Santa Ana, Its officers, employees, agents, volunteers and representatives are additional insureds, as respects general liability and auto liability, which
<br />is primary and non-contributory, subject to the terms and conditions of the policy, and attached forms. Separation of Insureds applies. Policies shall not be
<br />canceled or reduced In coverage or changed in any other material aspect without thirty (30) days prior written notice to the City, except 10 day notice for
<br />non-payment of premium.
<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 />20 Civic Center Plaza ACCORDANCE WITH THE POLICY PROVISIONS.
<br />Santa Ana, CA 92701
<br />AUTHORIZED REPRESENTATIVE Ptak Ms„rvVpu,.,,�,,�
<br />'anba ad DMelmt
<br />b REVIEWED & APPROVED BY:
<br />ACORD 25 (2016103) ©1988-2015 ACORD C
<br />F P. V:L61., 41
<br />The ACORD name and logo are registered marks of ACORD Risk Management Analyst
<br />
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