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Digitally signed
<br />.A — — 1 1-1 I 1 l: 1 �j.IKStK 1-f11 An TE (MMIDDIYYYYILI
<br />`oRo I CERTIFICATE OF LIABILITY SURANC �.q fDatate:20 2.033302022
<br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CO E I VHftt5W.Q&AI&$F'(cJQbER. THIS
<br />CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
<br />BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
<br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
<br />IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed.
<br />If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
<br />this certificate does not confer rights to the certificate holder in lieu of such endorsements .
<br />PRODUCER License # 0633339
<br />CONTACT
<br />Olson Duncan Insurance Service Inc.
<br />25550 Hawthorne Blvd. Suite 203
<br />PHONE FAX
<br />AIc, No, Eat): (310) 373-6441 A/C, No):(310) 378-5336
<br />Torrance, CA 96505 -
<br />5M,$,Ins@olsonduncan.com
<br />INSURER(SI AFFORDING COVERAGE
<br />NAIC #
<br />INSURER A: Sentinel Insurance Company LTD
<br />11000
<br />INSURED
<br />INSURER B: Employers Comp Ins CO
<br />11512
<br />INSURER C :
<br />ADR Services, Inc.
<br />1900 Avenue of the Stars # 200
<br />Los Angeles, CA 90067
<br />INSURER D
<br />INSURER E
<br />INSURER F
<br />COVERAGES CFRTIFIOATF.NIIMRFR- REVIQInu unue�s.
<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 />TYPE OF INSURANCE
<br />AOOL
<br />SUBR
<br />POLICY NUMBER
<br />POLICY EFF
<br />8/3012021
<br />POLICYEXP
<br />8/3012022
<br />LIMITS
<br />A
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />CLAIMS -MADE OCCUR
<br />-
<br />72SBANK4223
<br />EACH OCCURRENCE
<br />$ 2,000,000
<br />DAMAGE TO RENTED
<br />100,000
<br />MED EXP An ane erson
<br />10,D00
<br />PERSONAL& AOV INJURY
<br />2,000,000
<br />AGGREGATE LIMIT APPLIES PER:
<br />POLICY LOC
<br />GENERALAGGREGATE
<br />4,000.,0.00
<br />GEN'L
<br />X
<br />PRODUCTS - COMP/OP AGO
<br />4,000,000
<br />OTHER:
<br />A
<br />AUTOMOBILE
<br />LIABILITY
<br />-
<br />COMBI EU SINGLE LIMIT
<br />E.Lif don
<br />2,000,00
<br />ANY AUTO -
<br />OWNED SCHEDULED
<br />AUTOS ONLY AUTOS -
<br />AUTOS ONLY X AlO1TN05 ONLY
<br />2SBANK4223
<br />8130/2021
<br />8130/2022
<br />BODILY INJURY Perperson)
<br />BODILY INJURY Per accident
<br />X
<br />I(20PERTY AMAGE
<br />er accident
<br />A
<br />X
<br />UMBRELLA LIAR
<br />EXCESS LIAB
<br />X
<br />OCCUR
<br />CLAIMS -MADE
<br />72SBANK4223
<br />8130/2021
<br />8/3012022
<br />EACH OCCURRENCE
<br />1,000,000
<br />AGGREGATE
<br />1,000,00
<br />OED I X I RETENTION$ 10,000
<br />B
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY
<br />OFFICERIMEMBEgwq EXCLUDED?ECUTIVE Y�
<br />(Man datoryin NH)
<br />It yes, describe under
<br />DE SCRIPTION OF OPERATIONS below
<br />NIA
<br />EIG283201602
<br />4/15/2021
<br />101112021
<br />X I PERT,TE I I OTH-
<br />E.L. EACH ACCIDENT
<br />1,000,OD0
<br />E.L. DISEASE -EA EMPLOYE
<br />11000,000
<br />E.L. DISEASE -POLICY LIMIT
<br />1 1,000,000
<br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
<br />Certificate holder is an Add'I Insured CA per form SS00080405 If required by written contract or agreement.
<br />Insured has Professional Liability Insurance as follows:
<br />Allied World Insurance, policy #0312-3517, policy period: 5/17121-22
<br />$3,000,000 Each Claim
<br />$3,000,000 Aggregate
<br />$50,000 Retention
<br />SEE ATTACHED ACORD 101
<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 WILL BE DELIVERED IN
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />AUTHORIZED REPRESENTATIVE
<br />_�,
<br />ACORD 25 (2016/03) @ 1988.2015 ACORD
<br />The ACORD name and logo are registered marks of ACORD
<br />hg+Y-'"'-a>
<br />Riek MArMgemNd Dbislmt
<br />REVIEWED fi APPROVED BY: -_
<br />Al.�:a Acavrdo
<br />Risk ldanagemen[ Specialist
<br />
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