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Tori Pierson D.It.:2,21910..708:3830-0)'00'
<br />AcoRDF CERTIFICATE OF LIABILITY INSURANCE
<br />DATE IMMNOIYYYY)
<br />09/27/2021
<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 NEGATIVELYAMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
<br />BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURERIS), 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 endomement(s).
<br />PRODUCER
<br />CONTACT Jennie Garcia
<br />NAME:
<br />The Empire Company
<br />PHONE (714) 636-9945 FAX 14 636-9946
<br />No Eat: AI Na: )
<br />550 North Park Canter Drive
<br />6M L
<br />igarDlB(t�emplfedO.I'Am
<br />Suite 205
<br />ADDRE66:
<br />INSURER(S)AFFORDING COVERAGE
<br />NAICa
<br />Santa Ana
<br />INSURER, Ohio Security Insurance Company
<br />24082
<br />CA 92705
<br />INSURED
<br />INSURER 9: American Fire and Casualty Insurance Company
<br />24066
<br />Transportation Studies Inc
<br />INSURER C: United States Liability Insurance Company
<br />26895
<br />2640 Walnut Ave Ste L
<br />INSURER o:
<br />INSURERS:
<br />Tustin CA 92780
<br />INSURERF:
<br />THIS IS TO CERTIFY THATTHE 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 OFANY CONTRACTOR OTHER DOCUMENT WITH RESPECTTO WHICH THIS
<br />CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCEAFFORDED BYTHE POLICIES DESCRIBED HEREIN IS SUBJECTTO ALLTHETERMS,
<br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
<br />INSR
<br />LTR
<br />TYPEOFINSURANCE
<br />ADDLSUBR
<br />INSO
<br />wVD
<br />POUCYNUMSER
<br />DUC
<br />MMIDo1YYYY
<br />P UCYEXP
<br />MMIDWYYYY
<br />UMRa
<br />COMMERCIAL GENERAL LU191LnY
<br />EACH OCCURRENCE
<br />$ 1,000,000
<br />PREMISES En wnerwx
<br />S 500,000
<br />CLAIMSMAOE © OCCUR
<br />MEO EXP(Anono croon)
<br />s 15,DDO
<br />PERSONALBADVINJURY
<br />s 1,000,000
<br />A
<br />BKS59050934
<br />10/0112021
<br />10101/2022
<br />GEN'LAGGREGATE LIMIT APPUES PER:
<br />❑
<br />GENERALAGGREGATE
<br />S 2,000.000
<br />PRODUCTS-CCMPMPA(0(1
<br />$ 2,000.000
<br />POLICY JECT LOC
<br />S
<br />OTHER:
<br />AUTOMOBILE
<br />UAGIUTV
<br />COMBINED SINGLE LIMN
<br />Ee acddma
<br />$ 1,000,000
<br />a001LV INJURY (Per person)
<br />S
<br />ANYAUTO
<br />A
<br />OwMEO SCHEDUIEO
<br />AUTOS ONLY AUTOS
<br />BAS59D50934
<br />10/0112021
<br />10/0112022
<br />BODILY INJURY (Pereaitle n0
<br />E
<br />HIRED NON�OWNED
<br />AUTOS ONLY AUTOS ONLY
<br />PeOreEw.tlrY DAMAGE
<br />s
<br />Uninsured motorist
<br />s 1,000,000
<br />UMBRELLA LIAa
<br />OCCUR
<br />E/.CHOCCURRENCE
<br />$ 1,000,000
<br />8
<br />EXCESSUAe I
<br />I CLAIMSMADE
<br />USA59050934
<br />10/01/2021
<br />10/01/2022
<br />AGGREGATE
<br />$ 1.000,000
<br />DEO IX RETENRON S 10,000
<br />s
<br />VON
<br />_
<br />%� �
<br />AND EMPLOYERS LIABILITY
<br />AND EMPLOYERS' LIA6ILRY YIN
<br />TUTE ER
<br />E.EACHACCIOENT
<br />s 1,000,000
<br />A
<br />ANY PROPRIETORIPARTNER/EXECUTIVE
<br />OFRCERm1EMSER EXCLUDED➢
<br />NIA
<br />XWS59050934
<br />10/Ot12021
<br />10/O7/2022L
<br />(Mandalory in NH)
<br />E.L. DISEASE. EA EMPLOYEE
<br />s 1,000,000
<br />Ilya$, do$cHbauntler
<br />E.LDISEA$E-POUCYUMIT
<br />S 11000,000
<br />DESCRIPTION OF OPERATIONS W.
<br />Errors 80misaions
<br />Each Claim
<br />$1.000,000
<br />C
<br />SP1022743J
<br />10/0112021
<br />10/01/2022
<br />Aggregate
<br />$2,000.000
<br />DESCRIPTION OF OPERATIONS l LOCATIONS / VEHICLES (ACORD fat, Add final Remarks Schedule, may ba attached a more space Is regehad)
<br />Re: Agreement to Provide Traffic Counting Services on an On -Call Basis
<br />The City of Santa Ana, its officers, employees, agents, volunteers and representatives are named as additional insureds with primary/non-contributory
<br />wording in respect to the general coverage per forms CG88100413 attached as required by written Contract
<br />L!liabilry
<br />City of Santa Ana, Risk Management Division,
<br />4th Floor
<br />20 Civic Center Plaza
<br />Santa Ana
<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 />AUTHORRED REPRESENTATIVE
<br />CA 92702 RNIr Margemad IX.®an
<br />y,µaa ,erl •'� rRv�wm6AroRo,I®Be
<br />81.+
<br />V lace-AUTJ AGUKU
<br />ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD R^kA�^'smmroa�Iane
<br />
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