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<br />,a►coRn® CERTIFICATE OF LIABILITY I E n
<br />by An
<br />DATE(MMlDDIYYYY)
<br />le 1012912021
<br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RitHTS UPON ' HL/ If� HOLDER. THIS
<br />CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND ORALTE E COVER iE /N B THE POLICIES
<br />BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTR T "®atAem2;0,2,2A�lifED
<br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
<br />IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITICN'.L INSURRMUSIS
<br />Wi7,'6ZH_do'rsed.
<br />If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies m i+_, 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 />2345 Grand Blvd., Suite 400
<br />Kansas City MO 64108
<br />CONTACT
<br />NAME:
<br />PHONE
<br />oN Me, Ext: 816-421-7788 FAAIc No): 816-472-,5517
<br />EMAIL
<br />ADDRESS: GCSSFCerts a' .corn
<br />INSURER(S) AFFORDING COVERAGE
<br />NAIC #
<br />INSURER A: Zurich American Insurance Company
<br />16535
<br />License#'. BR-724491
<br />INSURED PATRENV-02
<br />Patriot Environmental Services, Inc.
<br />INSURER B : Steadfast Insurance Company
<br />26387
<br />508 East E. Street, Unit
<br />INSURERC:
<br />INSURERD:
<br />Wilmington, CA 90744
<br />INSURER E :
<br />INSURER F:
<br />COVERAGES CERTIFICATE NUMBER:1345643605 REVISION NUMBER:
<br />THIS IS TO CERTIFY THAT THE POLIO€ES 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 />ADDL
<br />INSR
<br />SUBR
<br />WVD
<br />POLICYNUMBER
<br />POLICY EFF
<br />MMlDDIYYYY
<br />POLICY EXP
<br />MMIDDIYYYY
<br />-
<br />LIMITS
<br />A
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />GPL-6024753-01
<br />1111/2021
<br />111112022
<br />EACH OCCURRENCE
<br />$2,000,000
<br />CLAIMS -MADE � OCCUR
<br />DAMAGETORENTED
<br />PREMISES Ea occurrence
<br />$ 100,000
<br />MED EXP (Any one person)
<br />$ 5,000
<br />PERSONAL & ADV INJURY
<br />$2,000,000
<br />GEN'LACGREGATE LIMIT APPLIES PER:
<br />GENERALAGGREGATE
<br />$4,000-,000
<br />POLICY I PE O 171 LOG
<br />PRODUCTS - COMPIOP AGG
<br />$ 4,000,000
<br />$
<br />17 OTHER:
<br />A
<br />AIITOMOBILELIABILiTY
<br />BAP 5682677-01
<br />1111t2021
<br />1111/2022
<br />COMBINED SINGLE LIMIT
<br />Ea accider
<br />$ 1,000,000
<br />X
<br />BODILY INJURY (Per person)
<br />$
<br />ANY AUTO
<br />OWNED SCHEDULED
<br />AUTOS ONLY AUTOS
<br />SOD ILY INJURY (Per accident)
<br />$
<br />HIRED NON -OWNED
<br />AUTOS ONLY AUTOS ONLY
<br />PROPERTY DAMAGE
<br />Per accident
<br />$
<br />B
<br />UMBRELLALIAB
<br />X
<br />OCCUR
<br />SXS 6182421-01
<br />11/112021
<br />11H12022
<br />EACH OCCURRENCE
<br />$ 10,000,000
<br />X
<br />AGGREGATE
<br />$10,000, 000
<br />EXCESS LIAR
<br />CLAIMS -MADE
<br />DED X RETENTION $ n
<br />$
<br />A
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY YIN
<br />WC 5682678-01
<br />111112021
<br />11/1/2022
<br />X I PER OTH-
<br />STATUTE ER
<br />E.L. EACH ACCIDENT
<br />$ 1,000,000
<br />ANYPROPRIETORIPARTNERlEXECUTIVE
<br />OFFICERIMEMBER EXCLUDED?
<br />NIA
<br />E,L. DISEASE - EA EMPLOYEE
<br />-
<br />$ 1 000,000
<br />(Mandatory in NH)
<br />If yes, describe under
<br />E.L- DISEASE - POLICY LIMIT
<br />S 1 000,000
<br />DESCRIPTION OF OPERATIONS below
<br />A
<br />Canlractofs Pollution
<br />GPL-6024753-01
<br />111112121
<br />11/1/2022
<br />Per OcclPer Claim
<br />1,000.000
<br />Professional Liability
<br />Aggregate
<br />Deductible Per Claim
<br />1,000.000
<br />20,000
<br />DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
<br />City of Santa Ana its officers, employees, agents, volunteers and representatives are Additional Insured(s) as per the attached endorsement or policy language.
<br />Insurance provided to Additional Insured(s) is primary and non-contributory as per the attached endorsements or policy language.
<br />CERTIFICATE HOLDER CANCELLATION
<br />City of Santa Ana
<br />Risk Management Division, 4th Floor
<br />20 Civic Center Plaza
<br />Santa Ana CA 92702
<br />USA
<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 />ORIZED REPRESENTATIVE
<br />O 1988-2015 ACORD
<br />ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
<br />RiskMlvwganadDiMalrm
<br />�+ G REVIEWED & APPROVE BY:
<br />Risk Management Specialist
<br />
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