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Digi[ally signed by Tod Pierson
<br />Tori Pierson Date: Z@].g52$,i:e,:g4
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<br />AC"RO® CERTIFICATE OF LIABILITY INSURANCE
<br />k.l
<br />DATE(MMIDD/YYYY)
<br />5/20/2022
<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 rights to the certificate holder in lieu of such endorsement(s).
<br />PRODUCER
<br />Arthur J. Gallagher Risk Management Services, Inc.
<br />4200 Corporate Drive Ste 160
<br />West Des Moines IA 50266
<br />CONTACT lCla Smith
<br />NAME: Tr
<br />PHONE . 515-309-6218 FAX
<br />AIc Na:
<br />`MA Ess: tricia smith a' .com
<br />6EDOR
<br />INSURERS AFFORDING COVERAGE
<br />NAIC#
<br />INSURERA: James River Insurance Company
<br />12203
<br />INSURED
<br />Elliott Auto Supply Co., Inc. Factory Motor - Part
<br />1380 Corporate Center Curve, Ste 200
<br />INSURERS: Lloyd's S nd 623 (Beazley Furlongs Ltd)
<br />INSURER c: Employers Mutual Casualty Company
<br />21415
<br />INSURER D:
<br />Eagan, MN 55121
<br />INSURER E :
<br />INSURER F :
<br />COVERAGES CERTIFICATE NUMBER: 1032648748 REVISION NUMRFR-
<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 />INSR
<br />LTR
<br />TYPE OF INSURANCE
<br />ADDLSUBR
<br />INSD
<br />WVD
<br />POLICYNUMBER
<br />POLICY EFF
<br />MWDDM
<br />POLICY EXP
<br />MM/DDryYYY
<br />LIMITS
<br />C
<br />X
<br />COMMERCIALGENERAL LIABILITY
<br />CLAIMS -MADE OCCUR
<br />Y
<br />Y
<br />2D39543
<br />11/15/2021
<br />11/15/2022
<br />EACH OCCURRENCE
<br />$1.000,000
<br />DAMAGE TO RENTED
<br />PREMISES Ea occurrence
<br />$1,000,000
<br />MED EXP(Any one person)
<br />$5,000
<br />PERSONAL B ADV INJURY
<br />$1,000.000
<br />GEN'L
<br />AGGREGATE LIMIT APPLIES PER:
<br />POLICY 0 PE` I LOG
<br />GENERAL AGGREGATE
<br />$2.000.000
<br />PRODUCTS - COMP/OP AGG
<br />$2,ODO,000
<br />I Property Damange
<br />$ 1,000,000
<br />OTHER
<br />I
<br />C
<br />C
<br />AUTOMOBILE
<br />LIABILITY
<br />ANY AUTO
<br />Y
<br />2139543
<br />2E39543
<br />11/15/2021
<br />11/15/2021
<br />11/15/2022
<br />11/15/2022
<br />COMBINED SINGLE LIMIT
<br />a accident)ILY
<br />$1,000,000
<br />B (Per Person)
<br />$
<br />OWNED SCHEDULEDAUTOS ONLY AUTOS
<br />JX
<br />BODILY INJURY (Per accident)
<br />$
<br />HIRED X NON -OWNED
<br />AUTOS ONLY AUTOS ONLY
<br />PROPERTY DAMAGE
<br />Par acoideot
<br />$
<br />Ded Com Callaion
<br />$1,000
<br />C
<br />X
<br />UMBRELLALUIB
<br />X
<br />OCCUR
<br />2J39543
<br />11/15/2021
<br />11/15/2022
<br />EACH OCCURRENCE
<br />$4,000,000
<br />AGGREGATE
<br />$4,000,000
<br />EXCESS Lure
<br />'LA "MADE
<br />DEC X RETENTION$ 1 A nnn
<br />$
<br />C
<br />C
<br />C
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS'LIABILRY YIN
<br />ANYPROPRIETOR/PARTNEWEXECUTIVE
<br />OFFICERIMEMBEREXCWOEDy FNI
<br />NIA
<br />2N39543
<br />2P39543
<br />2M39543
<br />11/15/2021
<br />11/15/2021
<br />11/15/2021
<br />11/15/2022
<br />11/15/2022
<br />11/15/2022
<br />X PER OTFF
<br />STATUTE ER
<br />statutory
<br />E.L. EACH ACCIDENT
<br />$1,000,000
<br />E.L. DISEASE -EA EMPLOYE
<br />$1,000.000
<br />(Mandatary in NH)
<br />If yes, describe under
<br />E.L. DISEASE -POLICY LIMIT
<br />$1,000.000
<br />DESCRIPTION OF OPERATIONS below
<br />C
<br />A
<br />B
<br />GARAGE LIABILITY
<br />Excess Umbrella
<br />Cyber Liability
<br />2E39543
<br />001097701
<br />W171413210701
<br />11/15/2021
<br />11/15/2021
<br />2/l/2021
<br />11/15/2022
<br />11/15/2022
<br />2/1/2022
<br />Auto Only- Ea A.
<br />Other Than - Ea A.
<br />Each Agg
<br />$500.000
<br />$1,000.000
<br />$5,000,000
<br />DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached it more space is required)
<br />Elliott Auto Supply Co., Inc. inclusive of Factory Motor Parts and Splash Products
<br />RE: Project #A-2019-085
<br />The City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California 92702; its officers, employees, agents and volunteers are included as Additional Insured
<br />under the General Liability policy per form CG7184 (10/13) and auto liability policy per form CA7270 (03107) as per written contract requirement pursuant to and
<br />subject to the policy's terms, definitions, conditions, and exclusion. The insurance provided in the General Liability policy is Primary and Non -Contributory and
<br />any other insurance shall be excess only, and not contributing per form CG7184 (10/13) as per written contract requirement pursuant to and subject to the
<br />policy's terms, definitions, conditions, and exclusion. Waiver of Subrogation applies to the Additional insureds as respects to the General Liability per form
<br />CG7555 (4/13), pursuant to and subject to the policy's terms when required in a written contract or agreement per form
<br />City of Santa Ana
<br />Risk Management Division
<br />20 Civic Center Plaza
<br />Santa Ana CA 92702
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />THE EXPIRATION DATE THEREOF, NOTICE
<br />WILL BE DELIVERED IN
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />AUTHORIZED REPRESENTATIVE
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<br />ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD v
<br />
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