Item 22 - On -Call Emergency Asphalt Concrete, Concrete, and Storm Drain Repair Services

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® ACCOR" �CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 7/5/2023 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAME: PFA Western Republic Insurance Services PHONE 714.536.0500 A/C, No, Ext : (A/C, No): ADDRESS: dustin@wrinsurance.com 19900 Beach Blvd INSURER(S) AFFORDING COVERAGE NAIC # Suite F1 INSURER A : BERKLEY ASSURANCE CO 39462 Huntington Beach CA 92648 INSURED INSURER B : STATE COMPENSATION INS 35076 INSURER C : J & L Constructors Inc INSURER D : 29104 Basswood INSURER E : INSURER F : Lake Elsinore CA 92530 COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER YL;" (MMIDD/FL)LIL;Y LA (MM/DD/YYYY) LIMITS A )C COMMERCIAL GENERAL LIABILITY CLAIMS -MADE FKI OCCUR Y Y VUMA0310930 04/27/2023 04/27/2024 EACH OCCURRENCE $ 1,000,000 PREMISES (Ea occurrence) $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL a ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRO- F7 POLICY ETECT LOC OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 $ AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ UAMAGE (Per accident) $ A UMBRELLA LIAB EXCESS LIAB x OCCUR CLAIMS -MADE VUMA0310940 04/27/2023 04/27/2024 EACH OCCURRENCE $ 5,000,000 X AGGREGATE $ 5,000,000 DED I I RETENTION $ $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y I N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N/A Y 9170623-22 12/03/2023 12/03/2024 - STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Those usual to the insured's operations. The certificate is named as additional insured per the attached MEGL 0009-01 09 18. Waiver of subrogation applies per the attached CG 24 04 12 19 and 10217 (REV.4-2018). A 30-day written notice of cancellation is applicable. A 30-day written notice of cancellation is applicable. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Orange County Fire Authority ACCORDANCE WITH THE POLICY PROVISIONS. 1 Fire Authority Road AUTHORIZED REPRESENTATIVE Irvine, CA 92602 puyiiry Kee_" © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD