|
/
<br />A� " CERTIFICATE OF LIABILITY INSURANCE
<br />DATE (MM/DD/YYYY)
<br />08/06/2024
<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 Nataly Hague CISR
<br />NAME:
<br />_James G. Parker Insurance_
<br />PHONE
<br />�Xt : (559) 222-7722 FAXNo: (559) 222-1724
<br />License #0554959
<br />P O Box 3947
<br />Angie Acevoe(
<br />MAIL
<br />DDRESf
<br />INSURE (S) AFFO DING COVERA E
<br />NAIC #
<br />s A: i �itle i e l o —
<br />•
<br />3
<br />Fresno
<br />INSURED
<br />INSURER B : Infinity Select Insurance Co
<br />20260
<br />Superior Hot Tapping Services Inc
<br />INSURER C : Scottsdale Insurance Company
<br />41297
<br />Superior Are Welding Inc
<br />INSURERD: State Compensation Ins Fund
<br />35076.
<br />7923 Old Oak Court
<br />INSURER E: Evanston Insurance Company
<br />35378
<br />INSURER F :
<br />Riverside 92506
<br />COVERAGES CERTIFICATE NUMBER: 24-25 WC BA GL UMB 23- REVISION NUMBER:
<br />THIS IS TO CERTIFYTHAT 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 MAYBE 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 />ADDL
<br />UBR
<br />EFF
<br />O ICY EXP
<br />LTR
<br />TYPE OF INSURANCE
<br />INSD
<br />WVD
<br />POLICY NUMBER
<br />MM/DD YYYYMPOLICY
<br />DD YYYY
<br />LIMITS
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />EACH OCCURRENCE
<br />$ 1,000,000
<br />�
<br />DAMAGE
<br />100,000
<br />OCCUR
<br />PREM SESOEa occu«Dence
<br />$
<br />_7CLAIMS-MADE
<br />MED EXP (Any one person)
<br />$ 5,000
<br />PERSONAL & ADV INJURY
<br />$ 1,000,000
<br />A
<br />Y
<br />Y
<br />MPOO82001008411
<br />07/31/2024
<br />07/31/2025
<br />GEN'LAGGREGATE LIMITAPPLIES PER:
<br />GENERAL AGGREGATE
<br />$ 2,000,000
<br />POLICY PRO ❑
<br />JECT LOC
<br />PRODUCTS - COMP/OPAGG
<br />2,000,000
<br />$
<br />$
<br />OTHER:
<br />AUTOMOBILE
<br />LIABILITY
<br />COMBINED SINGLE LIMIT
<br />$ 1,000,000
<br />Ea accident
<br />X
<br />BODILY INJURY (Per person)
<br />$
<br />ANYAUTO
<br />B
<br />OWNED SCHEDULED
<br />50001616301
<br />01/06/2024
<br />01/06/2025
<br />BODILY INJURY (Per accident)
<br />$
<br />AUTOS ONLY AUTOS
<br />PROPERTY DAMAGE
<br />$
<br />HIRED NON -OWNED
<br />AUTOS ONLY AUTOS ONLY
<br />Per accident
<br />X
<br />UMBRELLA LIAB
<br />X
<br />OCCUR
<br />EACH OCCURRENCE
<br />$ 2,000,000
<br />AGGREGATE
<br />$ 2,000,000
<br />C
<br />EXCESSLIAB
<br />CLAIMS -MADE
<br />XLS1228052
<br />07/31/2024
<br />07/31/2025
<br />DED I I RETENTION $
<br />1
<br />$
<br />WORKERS COMPENSATION
<br />X1
<br />AND EMPLOYERS' LIABILITY Y / N
<br />SPER TATUTE EORH
<br />E.L. EACH ACCIDENT
<br />1,000,000
<br />$
<br />D
<br />ANY PROPRIETOR/PARTNER/EXECUTIVE
<br />F
<br />NIA
<br />Y
<br />9334957-2024
<br />03/15/2024
<br />03/15/2025
<br />1,000,000
<br />OFFICER/MEMBER EXCLUDED?
<br />(Mandatory in NH)
<br />E.L. DISEASE- EA EMPLOYEE
<br />$
<br />If yes, describe under
<br />1,000,000
<br />DESCRIPTION OF OPERATIONS below
<br />E.L. DISEASE- POLICY LIMIT
<br />$
<br />Aggregate - Limit
<br />$2,000,000
<br />Contractors Pollution w/Incidental
<br />E
<br />Professional Liability
<br />CPLMOL120711
<br />12/21/2023
<br />12/21/2024
<br />Each Pollution Condition
<br />$2,000,000
<br />Each Act- E & O
<br />$2,000,000
<br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
<br />RE: Project #2021-31,SR-55/Ritchey Street Water Improvements. James W Fowler Co (Contractor), City of Santa Ana (Owner), and Owner's Consultants
<br />where required by written contract, are included as additional insured with waiver of subrogation and Primary Non-contributory wording respects to General
<br />Liability per form CG2010 1185, CG2404 1093, CG2001 0413 attached. Waiver of subrogation applies to the Workers compensation per form 2572
<br />attached. Notice of Cancellation applies to workers compensation as per form 2065, attached. Umbrella Policy follows form.
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL RE DELIVERED IN
<br />City of Santa Ana Risk Management Division ACCORDANCE WITH THE POLICY PRO)
<br />20 Civic Center Plaza R[eleManag>�nenfDMs�rt
<br />AUTHORIZED REPRESENTATIVE ' REVIEWED br APPROVED BY.
<br />A Accvulo
<br />Santa Ana CA 92702}pj ® Risk Management Specialist
<br />© 1988-2015 ACOF
<br />ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
<br />
|