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PULLING-03
<br />SHIVAKUN
<br />OATD0IYYYY)
<br />4118/16/2024
<br />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(ies) must have ADDITIONAL INSURED provisions or be endorsed.
<br />If SUBROGATION IS WAIVED, subject to the terns and conditions of the policy, c rt may require an endorsement. A statement on
<br />Min
<br />t ' certificate does not confer rights to the certific it o e
<br />P c 7s
<br />B t rn I I�s ce Services Inc.
<br />9855 Scranto ad Acevedo
<br />Suite 100
<br />Sa iego, CA 92121 Date: 20
<br />N M :c my o
<br />PHONE FAX
<br />AIc,Nc, Eat: (858)255-3277 A/c, No>:(951)231-2572
<br />E-mr�IL . Ca1.CPU@Hubinternational.com
<br />DD E .
<br />I GCOVERAGE
<br />NAICN
<br />INSURER A: Regent Insurance Coman
<br />24449
<br />—
<br />UR —
<br />INSURER B: General Casualty Company of Wisconsin
<br />24414
<br />INSURER C : Great American Insurance Company
<br />16691
<br />Polly's Inc. Kentucky Fried Chicken Of Polly's, Inc.
<br />INSURER D : Pacific Compensation Insurance Company11555
<br />1150 E. Orangethrope Ave., Suite 101
<br />Placentia, CA 92870
<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 />ADOLSUBR
<br />POLICY NUMBER
<br />POLICY EFF
<br />POLICY EXPLTR
<br />LIMITS
<br />A
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />FU7CLAIMS-MADE OCCUR
<br />X
<br />X
<br />CGA1391303
<br />7/1/2023
<br />7/1/2024
<br />EACH OCCURRENCE
<br />$ 1,000,000
<br />DAMAGE TOE RENTED
<br />$ 100,000
<br />MED EXP (My one erson
<br />5,00g
<br />PERSONAL B ADV INJURY
<br />11000,000
<br />GENT
<br />X
<br />AGGREGATE LIMIT APPLIES PER:
<br />POLICY E zRT LOC
<br />GENERAL AGGREGATE
<br />25,000,000
<br />PRODUCTS - COMP/OP AGG
<br />2,000,000
<br />LIQUOR LIAB AGG
<br />2,000,000
<br />OTHER:
<br />B
<br />AUTOMOBILE
<br />LIABILITY
<br />COMBINEDSINGLELIMIT
<br />100000
<br />BODILY INJURY Perperson)
<br />X
<br />ANYAUTO
<br />OWNED SCHEDULED
<br />AUTOS ONLY AUTOSW
<br />X
<br />X
<br />CBA1391303
<br />71112023
<br />7/1/2024
<br />BODILY INJURY Per accident
<br />EPIOPEItle^t AMAGE
<br />AUTOS ONLY AUTOS ONL�
<br />Ded Comp/Coll
<br />1,000
<br />C
<br />X
<br />UMBRELLALIAB
<br />X
<br />OCCUR
<br />EACH OCCURRENCE
<br />10,000,000
<br />AGGREGATE
<br />10,000,000
<br />EXCESS LIAB
<br />CLAIMS -MADE
<br />UMB 4370083
<br />711/2023
<br />711/2024
<br />DED X RETENTION$ 10,000
<br />D
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY YIN
<br />ANY PROPRIETORJPARTNERIEXECUTIVE ❑
<br />OFFICERIMEMBER EXCLUDED?
<br />(Mandatory In NH)
<br />H yes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />N /A
<br />X
<br />1D24198
<br />7/1/2923
<br />7/112D24
<br />X PER OTF4
<br />E
<br />EL EACH ACCIDENT
<br />11000,000
<br />E.L. DISEASE - EA EMPLOYEE
<br />$ 1,000,00D
<br />E.L DISEASE - POLICY LIMIT
<br />1,000,000
<br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101. Additional Remarks Schedule, may be aaached if more space is required)
<br />City of Santa Ana, its City Council, its officers, officials, employees, agents, and volunteers are Additional Insured With regard to the General Liability policy,
<br />when required by written contract, per the attached endorsement form CG8155 03109. Coverage is Primary & Non -Contributory with regard to the General
<br />Liability policy, when required by written contract, per the attached endorsement form CG2001 04113. Waiver of Subrogation applies to the General Liability
<br />Policy, when required by written contract, per the attached endorsement form CG8224 05112. Additional Insured applies with regard to the Auto Liability
<br />policy,
<br />per endorsement to follow from carrier. Primary & Non -Contributory wording applies to the Auto Liability policy, per endorsement to follow from carrier.
<br />Waiver of Subrogation applies to the Auto Liability policy, per endorsement to follow from carrier. Waiver of Subrogation applies to the Workers
<br />Compensation
<br />City of Santa Ana
<br />Attn: Stephanie Garcia
<br />20 Civic Center Plaza
<br />Santa Ana, CA 92701
<br />ACORD 25 (2016103)
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCEI
<br />THE E%PIRATION DATE THEREO
<br />ACCORDANCE WITH THE POLICY PR(
<br />AUTHORIZED REPRESENTATIVE
<br />2E�fGL`1 1-L—
<br />ED BEFORF
<br />Risk Marugoneat DMafm1
<br />REVIEWED & APPRovED Or
<br />'--�� Risk Management Spedaist
<br />of
<br />91988.2015 ACORD CORPORATION. All rights reserved.
<br />The ACORD name and logo are registered marks of ACORD
<br />
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