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Arthur J. Gallagher Risk Management Services, LLC <br />San Francisco, CA 94105 <br />Phone: (415)546-9300 <br />BATM11 <br />Invoice # 5195470 <br />1 of <br />ACCOUNT NUMBER <br />DATE <br />SANTAANA-1 <br />7/15/2024 <br />BALANCE DUE ON <br />AMOUNT DUE <br />7/8/2024 <br />$3,473,573.47 <br />City of Santa Ana <br />20 Civic Center Plaza, M-28 <br />Risk Management, 4th Floor <br />Gallagher <br />g <br />Santa Ana, CA 92701 <br />Insurance I Risk Management I Consulting <br />Excess Workers Comp <br />PolicyNumber: <br />ABL100000805 <br />Company: Response Indemnity Company of California Effective: <br />7/1/2024 <br />to 7/1/2025 <br />Item # <br />Trans Eff Date <br />Due Date <br />Trans <br />Description <br />Amount <br />34874868 <br />7/1/2024 <br />7/8/2024 <br />RENB <br />WC Buffer - $500K xs $1.5M SIR <br />$300,027.00 <br />Difference in Conditions <br />PolicyNumber: <br />ESP30001763404 <br />Company: Endurance American Specialty Ins Co Effective: <br />7/1/2024 <br />to 7/1/2025 <br />Item # <br />Trans Eff Date <br />Due Date <br />Trans <br />Description <br />Amount <br />34874912 <br />7/1/2024 <br />7/8/2024 <br />RENB <br />Primary EM/Flood - $5M part of $10M <br />$370,000.00 <br />34874916 <br />7/1/2024 <br />7/8/2024 <br />SLTX <br />Surplus Lines Taxes <br />$11,100.00 <br />34874919 <br />7/1/2024 <br />7/8/2024 <br />STFX <br />Stamping Fees <br />$666.00 <br />Excess Liability <br />PolicyNumber: <br />IXG677029A <br />Company: General Star Indemnity Company Effective: <br />7/1/2024 <br />to 7/1/2025 <br />Item # <br />Trans Eff Date <br />Due Date <br />Trans <br />Description <br />Amount <br />34982883 <br />7/1/2024 <br />7/15/2024 <br />RENB <br />Excess Liability Buffer- $1M xs $2M SIR <br />$1,750,000.00 <br />34982885 <br />7/1/2024 <br />7/15/2024 <br />SLTX <br />Surplus Lines Taxes - CA <br />$52,500.00 <br />34982887 <br />7/1/2024 <br />7/15/2024 <br />STFX <br />Stamping Fees - CA <br />$3,150.00 <br />Difference in Conditions <br />PolicyNumber: <br />LHD944859 <br />Company: Landmark American Insurance Company Effective: <br />7/1/2024 <br />to 7/1/2025 <br />Item # <br />Trans Eff Date <br />Due Date <br />Trans <br />Description <br />Amount <br />34874968 <br />7/1/2024 <br />7/8/2024 <br />RENB <br />Primary EM/Flood - $2.5M part of $10M <br />$185,000.00 <br />34874970 <br />7/1/2024 <br />7/8/2024 <br />CFEE <br />Carrier Policy Fee <br />$1,500.00 <br />34874984 <br />7/1/2024 <br />7/8/2024 <br />SLTX <br />Surplus Lines Taxes <br />$5,595.00 <br />34874989 <br />7/1/2024 <br />7/8/2024 <br />STFX <br />Stamping Fees <br />$335.70 <br />Excess Difference in Conditi <br />PolicyNumber: <br />MCQ0101224 <br />Company: Mt Hawley Insurance Company Effective: <br />7/1/2024 <br />to 7/1/2025 <br />Item # <br />Trans Eff Date <br />Due Date <br />Trans <br />Description <br />Amount <br />Please return this portion with your payment. Include your invoice number on your remittance to expedite processing. <br />City of Santa Ana <br />20 Civic Center Plaza, M-28 <br />Risk Management, 4th Floor <br />Santa Ana. CA 92701 <br />Please send your remittance to: <br />Arthur J. Gallagher Risk Management Services, LLC <br />P.O. Box 39735 <br />Chicago, IL 60694-9700 <br />BATM I 1 <br />Invoice # 5195470 <br />ACCOUNTNUMBER DATE <br />SANTAANA-1 7/15/2024 <br />7/8/2024 $3,473,573.47 <br />AMOUNT PAID <br />PAY ONLINE AT: WWW.AJG.COM/EZPAY <br />Gallagher <br />Insurance I Risk Management I consulting <br />