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ACRE) CERTIFICATE OF LIABILITY INSURANCE
<br />DATE IYYYY
<br />avzs122022
<br />Dzz
<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 />CONTACT
<br />PHONE FAX
<br />AX xo:
<br />FOUR EMBARCADERO CENTER, SUITE 1100
<br />CALIFORNIA LICENSE NO. D437153
<br />SAN FRANCISCO, CA 94111
<br />EJAgIL
<br />ADDRESS
<br />INSURERS AFFORDING COVERAGE
<br />NAIC#
<br />CN101403686-SCAL-CAS-22-23 GLALW CA
<br />INSURER A: Safety Nalional Casualty Corp.
<br />15105
<br />INSURED
<br />KAISER FOUNDATION HEALTH PLAN, INC,
<br />INSURER B
<br />INSURER C
<br />KAISER FOUNDATION HOSPITALS
<br />393 EAST WALNUT STREET
<br />PASADENA, CA 91188
<br />INSURER D
<br />INSURER E
<br />INSURER F :
<br />COVERAGES CERTIFICATE NUMBER: SEA-003811693-02 REVISION NUMBER: 2
<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 INSURANCEINSID
<br />AIJIJ1
<br />SUER
<br />POLICY NUMBER
<br />MMIDDYEFF
<br />MMIDD/YYXYY
<br />LIMITS
<br />A
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />CI -AIMS -MADE OCCUR
<br />GL4048017
<br />01/012022
<br />01/012023
<br />EACH OCCURRENCE
<br />S 5,000,000
<br />ERENTED
<br />PREMISESS ( Ea occurrence)
<br />S 5,000,000
<br />MED EXP (Any one person)
<br />S 10,000
<br />PERSONAL &ADV INJURY
<br />S 5,000,000
<br />AGGREGATE LIMIT APPLIES PER:
<br />POLICY PET TOO
<br />GENERALAGGREGATE
<br />S 5,000,000
<br />GEN'L
<br />X
<br />PRODUCTS-COMPIOPAGG
<br />S 5,000,000
<br />$
<br />OTHER:
<br />A
<br />A
<br />AUTOMOBILE
<br />X
<br />LIABILITY
<br />ANY AUTO
<br />CA6675880
<br />$5,000,000 SIR
<br />01/0112022
<br />01/01/2023
<br />COMBINED SINGLE -LIMIT
<br />Me accident
<br />$ 4,000000
<br />BODILY INJURY (Per person)
<br />S
<br />OWNED BCHEDULED
<br />AUTOS ONLY AUTOS
<br />BODILY INJURY (Peracciden0
<br />S
<br />HIRED NON -OWNED
<br />AUTOS ONLY HAUTOS ONLY
<br />PROPERTY DAMAGE
<br />Per accident
<br />s
<br />Is
<br />UMBRELLA LNB
<br />OCCUR
<br />EACH OCCURRENCE
<br />S
<br />AGGREGATE
<br />S
<br />EXCESS LU18
<br />CLAIMS -MADE
<br />DED I I RETENTIONS
<br />S
<br />A
<br />WORKERS COMPENSATION
<br />EMPLOYERS' LIABILITY YIN
<br />ANYPROPRIETOWPARTNEWEXECUTIVE
<br />OFFICERIMEMBEREXCWDEDT
<br />N/A
<br />SP4066154
<br />SIR. $5,000,000
<br />01/0112023
<br />X PER OH_
<br />STATUTE ER
<br />E.L. EACH ACCIDENT
<br />$ 5,000,000
<br />E.L. DISEASE -EA EMPLOYEE
<br />$ 5,000,000
<br />(Mandatory In NH)
<br />If yes, describe under
<br />E.L. DISEASE- POLICY LIMIT
<br />$ 5,000,000
<br />DESCRIPTION OF OPERATIONS below
<br />DESCRIPTION OF OPERATIONS I LOCATIONS VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required)
<br />REQUEST 9RC006161
<br />THE CITY OF SANTA ANA, ITS OFFICERS, OFFICIALS, EMPLOYEES AND VOLUNTEERS ARE INCLUDED AS ADDITIONAL INSURED AS RESPECTS GENERAL LIABILITY TO THE EXTENT REQUIRED BY
<br />WRITTEN CONTRACT. THE GENERAL LIABILITY POLICY IS PRIMARY AND NON-CONTRIBUTORY WHERE REQUIRED BY WRITTEN CONTRACT. POLICIES INCLUDE A WAIVER OF SUBROGATION
<br />WHERE REQUIRED BY WRITTEN CONTRACT AND ALLOWED BYLAW.
<br />CITY OF
<br />IC SANTA ANA20 I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />SANTA ANA, CA 92701 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />SANTA ANA, CA 92701 ACCORDANCE WITH THE POLICY PROVISIONS,
<br />AUTHORIZED REPRESENTATIVE
<br />Risk Mu agnrla,t D wipD
<br />r
<br />REVIEWED&APPROVED By.
<br />©1988-2016 ACORD CACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD '' Risk Management Anarylt
<br />
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