|
ACOR& CERTIFICATE OF LIABILITY INSURANCE
<br />DATE(MMMDn'YYY)
<br />11/10/2021
<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 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(les) 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 />CONTACT Susan HarO
<br />NAME:
<br />The Liberty Company Insurance Brokers
<br />PHONE (858) 487-3737 FAX (858) 487-3730
<br />AIC No E#'.sharo@libertycompany.com AIC No:
<br />Lic #9D79653
<br />E-M AL
<br />ADDRESS:
<br />16855 W Bernardo Dr.,#230
<br />INSURER(') AFFORDING COVERAGE
<br />NAIL#
<br />San Diego CA 92127
<br />INSURERA: Continental Casualty Company
<br />20443
<br />INSURED -
<br />INSURER B: Ohio Security Insurance Company
<br />24082
<br />TRB AND ASSOCIATES
<br />INSURER C: National Union Fire Insurance
<br />19445
<br />3180 CROW CANYON PL#216 -
<br />INSURER D. Employers Preferred Ins. Co.
<br />10346
<br />INSURER E: U. S. Specialty Insurance Co. -
<br />29599
<br />SAN RAMON CA 94583
<br />INSURER F:
<br />COVERAGES CERTIFICATE NUMBER: CL2111999657 REVISION NUMBER -
<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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
<br />CERTIFICATE MAYBE 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 />TYPEOFINSURANCE
<br />INSD
<br />MD
<br />POLICY NUMBER
<br />POLICY EFF
<br />MMIDD
<br />POUCY EXP
<br />MMIDD
<br />OMITS
<br />COMMERCIAL GENERAL URBILJTY
<br />_
<br />EACH OCCURRENCE
<br />$ 2,000,000
<br />CLAIMS -MADE © OCCUR-
<br />_
<br />RE TIED
<br />PREMISES Eaoccunence
<br />$ 1,000,000
<br />MED EXP (Any one person)
<br />$ 10,000
<br />PERSONAL&ADV INJURY
<br />$ 2,000,000
<br />A
<br />Y
<br />2097186534
<br />11/10/2021
<br />11/10/2022
<br />GEN'LAGGREGATE LIMITAPPUES PER:
<br />GENERALAGGREGATE
<br />$ 4,000,000
<br />POLICY ® JECOT LOG,
<br />PRODUCTS-COMPIOP AGG
<br />$ 4,000,000
<br />OTHER:
<br />BAIL
<br />$ 1,000
<br />AUTOMOBILE
<br />UABIUTY
<br />COMBINED SINGLE LIMIT
<br />Ea acclden
<br />S 1,000,000
<br />BODILY I NJURY(Per person)
<br />S
<br />ANYAUTO -
<br />-
<br />B
<br />OWNED SCHEDULED
<br />AUTOSONLY AUTOS,
<br />Y
<br />-
<br />BAS57021999
<br />11/18/2021
<br />11/18/2022
<br />BODILY INJURY(Par student)
<br />$
<br />HIRED NON -OWNED
<br />I PROPERTY DAMAGE
<br />Per accitlent
<br />$
<br />AUTOSONLY AUTOS ONLY
<br />$
<br />UMBRELLA LIAR
<br />x
<br />OCCUR
<br />EACH OCCURRENCE
<br />$ 2,000,000
<br />AGGREGATE -
<br />$ 2,000,000
<br />C
<br />EXCESS LIAB
<br />CLAIMS -MADE
<br />EBU033264259
<br />11/10/2021
<br />11/10/2022
<br />DEC
<br />I X1 RETENTION $ 0 -
<br />WORKERS COMPENSATION
<br />! PER OETH-
<br />AND EMPLOYERS' LIABIUTY YIN
<br />STATUTE
<br />EL. EACH ACCIDENT
<br />$ 1,000,ODD
<br />D
<br />ANY PROPRIETORIPARTNERIEXECUTIVE ❑
<br />OFFICER/MEMBER EXCLUDED?
<br />NIA
<br />Y
<br />EIG463819501
<br />11/10/2021
<br />11/10/2022
<br />EL DISEASE -EA EMPLOYEE
<br />$ 1.000,000
<br />(Mandatory in NH)
<br />If yes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />E.L. DISEASE -POLICY UMIT
<br />$ 1,D00,000
<br />Each Claim
<br />2,000,000
<br />Professional Liab
<br />E
<br />Retro Date 11/10/2006 -
<br />USS2132361
<br />11/10/2021
<br />11/10/2022
<br />Aggregate
<br />2,000,000
<br />Retention
<br />25,000
<br />DESCRIPTION OFOPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, may oe attached if more space is required)
<br />Whereby required by written contract or agreement, Cityof Santa Ana, its officers, employees, agents and representatives are included as additional insured
<br />with respect to general liability per form SB300176D-6-16 & SB146968B6-16 and auto liability perform AC85430618. Insurance is primary and
<br />non-contrbulory. Waiver of subrogation applies to workers compensation.
<br />30 Day notice of Cancellation.
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />City of Santa Ana ACCORDANCE WITH THE POLICY PROVISIONS.
<br />Risk Manangement Division
<br />AUTHORIZED REPRESENTATIVE Alit MarMgenlvRgr�nn
<br />20 Civic Center Plaza, 4th FI. V fteYaL & ArFnvvED �.
<br />Santa Ana CA 92701 41)" 'J#•u �iexdua
<br />f91U8I$-ZU1b ACUKU
<br />ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
<br />
|