|
Digitirson
<br />yTori
<br />Tori Pierson Datea2102.01.11615:15:16e08'00'
<br />ACOR" CERTIFICATE OF LIABILITY INSURANCE
<br />`..►�
<br />DAT1'MM/DD/YYYY)
<br />1/4/2022
<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 Bolton Insurance Services LLC
<br />CONT
<br />NAMEACT
<br />3475 E. Foothill Blvd., Suite 100
<br />Pasadena, CA 91107
<br />a"c°NN Ext: 626 799-7000 FVC,No: 626 583-2117
<br />E-MAIL
<br />ADDRESS:
<br />INSURER(S) AFFORDING COVERAGE
<br />NAIC #
<br />INSURERA: Zurich American Insurance Company
<br />16535
<br />www.boltonco.com 6004772
<br />INSURED
<br />United Storm Water, Inc.
<br />14000 East Valley Blvd.
<br />INSURER B: Steadfast Insurance Company
<br />26387
<br />INSURERC: Endurance Risk Solutions Assurance Co
<br />43630
<br />INSURER D7
<br />City of Industry CA 91746
<br />INSURER E :
<br />INSURER F :
<br />COVERAGES CERTIFICATE NUMBER: FFna71.27 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/YYYY
<br />POLICY EXP
<br />MM/DD/YYYY
<br />LIMITS
<br />A
<br />�/
<br />COMMERCIAL GENERAL LIABILITY
<br />✓
<br />GL0045648400
<br />12/31/2021
<br />12/31/2022
<br />EACH OCCURRENCE
<br />$1,000,000
<br />CLAIMS -MADE 11/1 OCCUR
<br />DA AGE RENTED
<br />'REMIS ESTo(Ea occurrence)
<br />$ 100,000
<br />MED EXP (Any one person)
<br />$ 5,000
<br />PERSONAL & ADV INJURY
<br />$ 1 ,000,000
<br />GEN'L
<br />AGGREGATE LIMIT APPLIES PER:
<br />GENERALAGGREGATE
<br />$2,000,000
<br />PRO -
<br />POLICY ✓� ECT LOC
<br />PRODUCTS - COMP/OP AGG
<br />$ 2,000,000
<br />$
<br />OTHER:
<br />A
<br />AUTOMOBILE
<br />LIABILITY
<br />BAP041471000
<br />12/31/2021
<br />12/31/2022
<br />Ee aBINEDtSINGLE LIMIT
<br />$ 1 ,000,000
<br />✓
<br />BODILY INJURY (Per person)
<br />$
<br />ANY AUTO
<br />OWNED SCHEDULED
<br />AUTOS ONLY AUTOS
<br />BODILY INJURY (Per accident)
<br />$
<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 />SXS096507000
<br />12/31/2021
<br />12/31/2022
<br />EACH OCCURRENCE
<br />$10,000,000
<br />AGGREGATE
<br />$ 10,000,000
<br />EXCESS LAB
<br />CLAIMS -MADE
<br />DED ✓ RETENTION $10,000
<br />$
<br />A
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY Y / N
<br />OFFICER/MEMBER EXCLUDED? ECUTIVE ❑N
<br />N /A
<br />WC045648700
<br />12/31/2021
<br />12/31/2022
<br />v/ STATUTE EERH
<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 />B
<br />Pollution Liability - Claims Made
<br />PEC068647700
<br />12/31/2021
<br />12/31/2022
<br />$15,000,000 Each Claim/Agg / $25,000 Ded.
<br />B
<br />Professional Liab - Claims Made
<br />PEC068647700
<br />12/31/2021
<br />12/31/2022
<br />$15,000,000 Each Claim/Agg / $25,000 Ded.
<br />C
<br />Excess Liability
<br />XSC30014805200
<br />12/31/2021
<br />12/31/2022
<br />$5Mil xs of $10Mil Ea Occ/Aggregate
<br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required)
<br />Re: Agreement #A-2021-097-02 & A2021-199 (1 st Amendment)
<br />GL Additional Insured applies per UGL2162ACW0219 attached, only if required by written contract/agreement.
<br />GL Primary & Non -Contributory Wording applies per UGL2162ACW0219 attached. Excess Policy follows form.
<br />Additional Insured(s): City of Santa Ana, its officers, agents, volunteers and employees.
<br />CERTIFICATE HOLDER CANCELLATION
<br />Agreement #A-2021-097-02
<br />City of Santa Ana
<br />Risk Management Division
<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 />Cassandra Rosales
<br />© 1988-2015
<br />ACORD 25 (2016103) The ACORD name and logo are registered marks of ACID
<br />66097137 1 UNITPUM-01 121-22 All Lines I Alias Lopez 11/4/2022 2:16:01 PM (PST) I Page 1 of 5
<br />
|