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Client#: 1400052
<br />Francine R. oiaiairysieoea ev r,andnee.vuia,eai
<br />MIDWETAP1 Villareal Da,e,2G21 I152-6-W
<br />ACORDTM CERTIFICATE OF LIABILITY INSURANCE
<br />DATE (MM/DD/YYYY)
<br />1/16/2022
<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 any rights to the certificate holder in lieu of such endorsement(s).
<br />PRODUCER
<br />CONTACT Jennifer Lake
<br />NAME:
<br />USI Insurance Services, LLC CL
<br />PHONE 567-803-4414 FAX
<br />One SeaGate, Suite 1800
<br />Ext :
<br />L(A/C, No):
<br />E-MAIL
<br />A
<br />ADDRESS: jennifer.lake@usi.com
<br />Toledo, OH 43604
<br />INSURER(S) AFFORDING COVERAGE
<br />NAIC #
<br />419 243-1191
<br />Transportation Insurance Company
<br />INSURERA: p P Y
<br />20494
<br />INSURED
<br />INSURER B : Continental Insurance Company
<br />35289
<br />Midwest Tape, LLC
<br />Continental Casualty Company
<br />INSURER C : Y P Y
<br />20443
<br />P.O. Box 820
<br />INSURER D:Midwest Employers Casualty Company
<br />23612
<br />Holland, OH 43528-0820
<br />Westchester Insurance Company
<br />INSURER E : p Y
<br />A57882
<br />INSURER F
<br />COVERAGES CERTIFICATE NUMBER: 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 CONTRACTOR 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 />ADDLSUBR
<br />INSR
<br />WVD
<br />POLICY NUMBER
<br />POLICY EFF
<br />MM/DD/YYYY
<br />POLICY EXP
<br />MM/DD/YYYY
<br />LIMITS
<br />A
<br />A
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />CLAIMS -MADE [* OCCUR
<br />OH Stop Gap
<br />X
<br />X
<br />X
<br />X
<br />C6071847392
<br />C6071847392
<br />05/09/2021
<br />05/09/2021
<br />05/09/2022
<br />05/09/2022
<br />EACH OCCURRENCE
<br />$1 ,000,000
<br />PREMI6ESOEaoNcurrDence
<br />s500,000
<br />MED EXP (Any one person)
<br />$15,000
<br />PERSONAL & ADV INJURY
<br />$1 ,000,000
<br />GEN'L
<br />AGGREGATE LIMIT APPLIES PER:
<br />PRO -
<br />POLICY JECT LOC
<br />OTHER:
<br />GENERAL AGGREGATE
<br />$2,000,000
<br />PRODUCTS-COMP/OPAGG
<br />$2,000,000
<br />$
<br />C
<br />AUTOMOBILE
<br />LIABILITY
<br />ANY AUTO
<br />OWNED SCHEDULED
<br />AUTOS ONLY AUTOS
<br />HIRED NON -OWNED
<br />AUTOS ONLY X AUTOS ONLY
<br />X
<br />X
<br />6071847408
<br />05/09/2021
<br />05/09/202
<br />COEaMBINED identSINGLE LIMIT
<br />acc
<br />1r 000r 000
<br />X
<br />BODILY INJURY (Per person)
<br />$
<br />X
<br />BODILY INJURY (Per accident)
<br />$
<br />PROPERTY DAMAGE
<br />Per accident
<br />$
<br />B
<br />X
<br />UMBRELLA LIAB
<br />EXCESS LIAB
<br />OCCUR
<br />CLAIMS -MADE
<br />X
<br />X
<br />6071847425
<br />05/09/2021
<br />05/09/2022
<br />EACH OCCURRENCE
<br />s15,000,000
<br />N
<br />AGGREGATE
<br />s15,000,000
<br />DED X RETENTION $0
<br />$
<br />C
<br />D
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY
<br />ANY PROPRIETOR/PARTNER/EXECUTIVE
<br />OFFICER/MEMBER EXCLUDED? nJ
<br />(Mandatory in NH)
<br />If yes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />N / A
<br />X
<br />X
<br />WC671847411
<br />EWC099148
<br />05/09/2021
<br />05/09/2021
<br />05/09/202
<br />05/09/202
<br />X PER OTH-
<br />STATUTE ER
<br />E.L. EACH ACCIDENT
<br />$1 ,000,000
<br />E.L. DISEASE - EA EMPLOYEE
<br />$1 ,000,000
<br />E.L. DISEASE - POLICY LIMIT
<br />$1 ,000,000
<br />E
<br />Cyber Liab/E&O
<br />X
<br />F15620304001
<br />05/09/2021
<br />05/09/2022
<br />$5,000,000 $50,000 ded.
<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 additionally insured .
<br />CERTIFICATE HOLDER CANCELLATION
<br />City of Santa Ana
<br />Risk Management Division
<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 />20 Civic Center Plaza 4th Floor
<br />Santa Ana, CA 92702 AUTHORIZED REPRESENTATIVE
<br />© 1988-2015 ACORD
<br />ACORD 25 (2016/03) 1 of 1 The ACORD name and logo are registered marks of ACORD
<br />#S34707632/M32197017
<br />cF RiskManagmentDMsian
<br />REVIEWED & APPROVED BY:
<br />v
<br />--� R(sk Mtanagennent Analyst
<br />
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