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<br />Piarcnn
<br />Tori Pierson
<br />Date: 2022.08.02
<br />ACORD 25 (2016103)
<br />�� •— --• • ICIv:v-U/UU FKUMAKN-U1
<br />J3ATRUSKOWSK1
<br />DAM t1
<br />7/15120YYYY)
<br />6/2022
<br />,a►`oRo CERTIFICATE OF LIABILITY INSURANCE
<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 pollcles may require an endorsement. A statement on
<br />this certificate does net confer ri his to the certificate holder In lieu of such endorsement(s .
<br />PRODUCER
<br />O TOT Anita Truskowski
<br />AssuredPartners of New Jersey, LLC dba AssuredPartners of Northeastern
<br />PA
<br />1130 Highway 315
<br />Wilkes Barre, PA 18702
<br />P ONE -- FAX
<br />A7c No EaI:(670 270.6075 A/C,No: 570270•6075
<br />EMAIL . anita.truskowski@assuredpartners.com
<br />-
<br />INSURERS AFFORDING COVERAGE NAICN
<br />INSURER A: National Interstate Insurance
<br />32620
<br />INSURED
<br />INSURERB:AXIS Surplus Insurance Co
<br />26620
<br />INSURER C:Travelers Casualty & Surety Co of America
<br />31194
<br />TACenergy, LLC
<br />INSURER O:
<br />PO Box 1481
<br />Texarkana, TX 75604
<br />--
<br />INSURER E
<br />INSURER F:
<br />COVERAGES CERTIFICATE NUMBER: 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 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 />ADDLSUBR INSD
<br />MD
<br />POLICY NUMBER
<br />POLICY EFF
<br />POLICY E%P
<br />LIMITS
<br />A
<br />X
<br />I COMMERCIAL GENERAL LIABILITY
<br />CLAIMS -MADE OCCUR
<br />X
<br />X
<br />GAL 4840025 00
<br />61112022
<br />61112023
<br />EACH OCCURRENCE
<br />S 2,000,000
<br />DAMAGE TO RENIED
<br />300,000
<br />TXX:xp—1 lution
<br />MED EXP A are arson
<br />S 5,000
<br />U
<br />PERSONAL&ADV INJURY
<br />S 2,000,000
<br />AGGREGATE LIMITAPPLIES PER:
<br />POLICY P LOC
<br />GENERAL AGGREGATE
<br />11 4,000,000
<br />GENL
<br />PRODUCTS - COMPIOP AGO
<br />S 4,000,000
<br />OTHER:
<br />EBLAGGREGATE
<br />S 1,000,000
<br />A
<br />AUTOMOBILE
<br />LIABILITY
<br />COMBINED SINGLE LIMIT
<br />'Ea accidenti
<br />2,000,000
<br />ANY AUTO
<br />OWNED SCHEDULED
<br />AUTO$ONLYMXAUTO
<br />X
<br />X
<br />GAL 4840025 00
<br />61112022
<br />6/1/2023
<br />BODILY INJURY Per person)
<br />]XX
<br />BODILYINJURYPer accident)
<br />o
<br />AUTO$ ONLY AER
<br />101TNOS ONLY
<br />¢1N&.50 Motor Cargo 41.000,000
<br />P �acccitlonl AMAOE
<br />A
<br />UMSRELLALIAB
<br />EXCESS LIAR
<br />X
<br />OCCUR
<br />I CLAIMS -MADE
<br />X
<br />X
<br />EXT0011343-01
<br />611/2022
<br />6/1/2023
<br />EACH OCCURRENCE
<br />4,000,000
<br />X
<br />AGGREGATE
<br />$ 4,000,000
<br />DED I X I RETENTIONS O
<br />WORKERS COMPENSATION
<br />ANDEMPLOVERS'LIABILITY YIN
<br />ANY CCPROWpPMReIIET99OEEWRARTNEMEXECUTIVE ❑
<br />EXCLUDED?
<br />NIA
<br />PER OTH-
<br />E.
<br />E.L.EACH ACCIDENT
<br />E.L. DISEASE - EA EMPLOYE
<br />S
<br />ImanUeloryln NH)
<br />If yes, describe under
<br />D
<br />DESCRIPTION OF OPERATIONS belax
<br />E.L. DISEASE -POLICY LIMIT
<br />S
<br />B
<br />Excess Liability
<br />P-001-000045045.05
<br />711/2022
<br />6N/2023
<br />2nd Layer
<br />5,000,000
<br />C
<br />Crime
<br />107663119
<br />711/2022
<br />71112023
<br />Employee Theft
<br />2,000,000
<br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES tACORD lei, Addxlonal Remarks Schedule, onebe attached I/ mare space Is requlred)
<br />3rd Layer Excess Liability Evanston Ins Co MKLV7EFX100903, 711122 to 6/1123, $5,006.000
<br />4th Layer Excess Liability Navigators Specialty Ins. Co. MR22EXCZOBTNLIC, 711122 to 611123, 55,000,000
<br />5th Layer Excess Liability Endurance American Ins Co ELD30002030702 711122 to 611123 $5,000,000
<br />City of Santa Ana, officers, agents, employees, and volunteers where required by written contract, are additional Insured as their Interest may appear and
<br />where required by written contract, but only With respect to the operations of the Named Insured on general liability per form CG2010 and business auto per
<br />form NICA5057. Waiver of Subrogation is applicable where required by written contract and subject to policy terms and conditions on general liability per
<br />SEE ATTACHED ACORD 101
<br />City of Santa Ana
<br />Risk Management Division
<br />20 Civic Center Plaza, 4th floor
<br />Santa Ana, CA 92701 AUTHlORDED REPRESENTATIVE
<br />emeoL aswtUNsl .
<br />`� REHermtAPraw®Br
<br />©1988-2015 ACORD COR �W� %mru �roWan
<br />The ACORD name and logo are registered marks of ACORD aekManager,nntlm Iaae
<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 />
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