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<br />Ejhjubmmz!tjhofe!cz!Gsbodjof!S/! <br />Wjmmbsfbm! <br />Gsbodjof!S/!Wjmmbsfbm <br />Ebuf;!3133/13/14!19;3:;52!.19(11( <br />DATE (MM/DD/YYYY) <br />CERTIFICATE OF LIABILITY INSURANCE <br />12/28/2021 <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 />CONTACT <br />PRODUCER <br />Liberty Mutual Insurance NAME: <br />FAX <br />PHONE <br />PO Box 188065 <br />800-962-7132800-845-3666 <br />(A/C, No): <br />(A/C, No, Ext): <br />Fairfield, OH 45018 <br />E-MAIL <br />BusinessService@LibertyMutual.com <br />ADDRESS: <br />INSURER(S) AFFORDING COVERAGENAIC # <br />INSURER A :Ohio Security Insurance Company24082 <br />INSURED <br />INSURER B :American Fire and Casualty Company24066 <br />Management Partners Inc. <br />INSURER C :Ohio Casualty Insurance Company24074 <br />1730 Madison Rd <br />INSURER D : <br />Cincinnati OH 45206 <br />INSURER E : <br />INSURER F : <br />COVERAGESCERTIFICATE NUMBER:REVISION NUMBER: <br />65918761 <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 />ADDLSUBR <br />INSRPOLICY EFFPOLICY EXP <br />TYPE OF INSURANCELIMITS <br />POLICY NUMBER <br />LTR(MM/DD/YYYY)(MM/DD/YYYY) <br />INSDWVD <br />COMMERCIAL GENERAL LIABILITY <br />ABKS578260573/1/20213/1/2022 <br />EACH OCCURRENCE$ <br />1,000,000 <br />DAMAGE TO RENTED <br />CLAIMS-MADEOCCUR$ <br />1,000,000 <br />PREMISES (Ea occurrence) <br />MED EXP (Any one person)$ <br />15,000 <br />PERSONAL & ADV INJURY$ <br />1,000,000 <br />2,000,000 <br />GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE$ <br />PRO- <br />POLICYLOCPRODUCTS - COMP/OP AGG$ <br />2,000,000 <br />JECT <br />$ <br />OTHER: <br />COMBINED SINGLE LIMIT <br />AUTOMOBILE LIABILITY$ <br />BBAA578260573/1/20213/1/2022 <br />1,000,000 <br />(Ea accident) <br />ANY AUTO <br />BODILY INJURY (Per person)$ <br />OWNEDSCHEDULED <br />BODILY INJURY (Per accident)$ <br />AUTOS ONLYAUTOS <br />NON-OWNED <br />HIREDPROPERTY DAMAGE <br />$ <br />(Per accident) <br />AUTOS ONLYAUTOS ONLY <br />$ <br />UMBRELLA LIAB <br />CUSO578260573/1/20213/1/2022 <br />EACH OCCURRENCE$ <br />5,000,000 <br />OCCUR <br />EXCESS LIAB <br />CLAIMS-MADEAGGREGATE$ <br />5,000,000 <br />0 <br />$ <br />DEDRETENTION$ <br />PEROTH- <br />WORKERS COMPENSATION <br />AXWS578260573/1/20213/1/2022 <br />STATUTEER <br />AND EMPLOYERS' LIABILITY <br />Y / N <br />ANYP ROPRIETOR/PARTNER/EXECUTIVE <br />E.L. EACH ACCIDENT$ <br />1,000,000 <br />N / A <br />OFFICER/MEMBER EXCLUDED? <br />(Mandatory in NH) <br />E.L. DISEASE - EA EMPLOYEE$ <br />1,000,000 <br />If yes, describe under <br />E.L. DISEASE - POLICY LIMIT$ <br />1,000,000 <br />DESCRIPTION OF OPERATIONS below <br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) <br />The City of Santa Ana, its officers, employees, agents, and representatives are named as additional insured on this policy pursuant to <br />written agreement, subject to Liability Broadening Extension, Blanket Additional Insured Provision. <br />CERTIFICATE HOLDERCANCELLATION <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />City of Santa Ana <br />THE EXPIRATION DATE THEREOF, NOTICE WILL 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 <br />Clara Gabriel <br />© 1988-2015 ACORD CORPORATION. All rights reserved. <br />ACORD 25 (2016/03)The ACORD name and logo are registered marks of ACORD <br />76:29872!}!68937168!}!32.33!HM!BV!VNC!XD!}!Dmbsb!Hbcsjfm!}!2303903132!23;49;4:!QN!)DTU*!}!Qbhf!2!pg!23 <br /> <br />