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A-2020-241-33-01
<br />Francine R. Villareal Digitally signed by Francine R. Villareal
<br />Date: 2021.07.1315:4153-07'00'
<br />A� o® CERTIFICATE OF LIABILITY INSURANCE
<br />DATEt061230212021 YYYY)
<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 />Marsh Risk & Insurance Services
<br />17901 Von Karman Avenue, Suite 1100
<br />(949) 399-5800, License N0437153
<br />Wine, CA 92614
<br />CONTACT
<br />NAME:
<br />ACNE Exit : aC No
<br />EMAIL
<br />ADDRESS:
<br />INSURER(S) AFFORDING COVERAGE
<br />NAIL
<br />Adn. NewportBeach.CerlRequest@mamh.com/F: 212-94BA323
<br />INSURER A: Crum & Forster Specially Insurance Cc
<br />44520
<br />CN115158923-01-01-21-22
<br />INSURED PlaceWorks, Inc
<br />INSURER B: Travelers Property Casualty Co. Of America
<br />25674
<br />INSURER C
<br />3 MacArthur Place, Suite 1100
<br />Santa Ana, CA 92707
<br />-
<br />INSURER 0:
<br />_-- -
<br />INSURER E:
<br />INSURER F:
<br />COVERAGES - CERTIFICATE NUMBER: LOS-002212046-27 RFVISION NIINI 19
<br />THIS IS TO'CERTIFY THAT THE POLICIES OF INSURANCE USTED BELOW HAVE, BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY 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 />LTA
<br />TYPE OF INSURANCE
<br />ADDLSUBR
<br />INSO
<br />we
<br />POLICYNUMBER
<br />POLICY EFF POLICY MP
<br />(MODDMMIDDIYYWI
<br />LIMITS
<br />A
<br />X
<br />I COMMERCIAL GENERAL LIABILITY
<br />CLAIMS -MADE � OCCUR-
<br />X
<br />X
<br />EPK135992
<br />07/0112021 0710112022
<br />EACH OCCURRENCE
<br />S 5,000,000
<br />PREMISES (Ea occu ante
<br />$ 50,000
<br />X
<br />MED EXP (Any one person)
<br />$ 5,000
<br />BI & PD Der. $5.000
<br />PERSONAL &ADV INJURY
<br />S 5,000,000
<br />AGGREGATE UMIT APPLIES PER
<br />POLICY PEA j LOC
<br />GENERALAGGREGATE
<br />S 5,000,000
<br />GENT
<br />X
<br />PRODUCTS - COMP/OPAGG
<br />S 5,000000
<br />Contractors Pollution
<br />S 5,000,000
<br />OTHER:
<br />B
<br />AUTOMOBILELUIBILITY
<br />X
<br />X
<br />BA11196406A214313
<br />0710112021 0710I2022
<br />COMBINED SINGLE LIMIT
<br />Ea accident
<br />5 1,000,000
<br />X
<br />ANY AUTO
<br />BODILY INJURY (Per person)
<br />S
<br />OWNED SCHEDULED
<br />AUTOS ONLY AS
<br />P
<br />BODILY INJURY (Per accident
<br />( )
<br />S
<br />HIRED NONDWNED
<br />AUTOS ONLY AUTOS ONLY
<br />PROPERTY DAMAGE
<br />Per accident
<br />S
<br />-
<br />Comp/Coll Deductibles
<br />S 1,000
<br />UMBRELLA LIAR
<br />N
<br />OCCUR
<br />EXBJ3287562143
<br />07/01/2021 07101/2022
<br />EACH OCCURRENCE
<br />S 4.000,000
<br />X
<br />EXCESS LIAR
<br />CLAIMS -MADE
<br />AGGREGATE
<br />S 4.000,000
<br />OED RETENTIONS
<br />1 5
<br />B
<br />WORKERS COMPENSATION
<br />'ANDEMPLOYERS'LUIBILITY YIN
<br />ANYPROPRIETOWPARTNERIEXECUTIVE
<br />OFMCEWMEMBEREXCLUDED? N
<br />I(Mandatory inNH)
<br />NIA
<br />UB7K7286762143G
<br />07101021 07/0112022
<br />g PER OTH-
<br />STATUTE ER
<br />E1- EACH ACCIDENT
<br />S 1,000,000
<br />—
<br />E.L. DISEASE -EA EMPLOYEE
<br />S 1.000,000
<br />If yes describe under
<br />DESCRIPTION OF OPERATIONS below
<br />EL. DISEASE -POLICY LIMIT
<br />S 1,000,000
<br />A
<br />Firms &Omissions -Claims Made
<br />EPKI35992
<br />07101021 07/0112022
<br />Each ClaimlAggregale
<br />5.000,000
<br />Ratio Dates: See 2nd Page
<br />DESCRIPTIONOFOPERATIONSILOCATIONSIVEHICLES (ACORD 101, Additional Remarks Schemes, may beratached N more space is required)
<br />Re: Operations performed by the named insured far the certificate holder
<br />City of Santa Ana, its officers, agents, employees, and volunteers are included as additional Insured where required by sadden contract wits respect to General and Auto Liability. This insurance is primary and non-
<br />contributory over any existing insurance and limited to liahilily ansing out of the operators of the named insured and where required by written contract with respect to General Liability_ Waver of subragabon is
<br />applicable where required by written contract with respect to General and Auto Liability.
<br />City of Santa Ana
<br />Risk Management Division
<br />20 Civic Center Plaza.4th Floor
<br />Santa Ana, CA 92701
<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 />of Marsh Risk & Insomorce Services
<br />Rosalynda Martinez Rom"
<br />©1988-2016
<br />ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
<br />Risk MaugemmtDMeion
<br />&c riEvIEWEo 6 APPROv®BY:
<br />g' � F4aDk�:+.4 R. V:tGDwLt
<br />�� Risk Management Analyst
<br />
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