|
ACORO® CERTIFICATE OF LIABILITY INSURAN6i DnTE(mnvoomYr)
<br />06/19/2024
<br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFER NO RIGHTS 'UPON THE CERTIFICATE HOLDER. THIS
<br />CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND iOR ALTER THE C VERAGE AFFORDED BY THE POLICIES
<br />BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN HE 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 ADDITIO AL INSURED provisions or be endorsed.
<br />If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may Squire an endorsement. A statement on
<br />this certificate does not confer rights to the certificate holder In lieu of such endorsements .
<br />PRODUCER C 1NEA I=
<br />® a 1ME: a
<br />Gregg Stapp InsuraAPN'c
<br />s_pE 1 I"810E.Commonwea' ' u - NESS: slapp6Qaol.com
<br />AF NAIC 4
<br />Fullerton CA 92831 _ r su. = A:, r e n
<br />INSURED .4 IL. National Specially In urance Company
<br />Upland SA&udty Group Inc. PPO # 119794 ., .4 Ara wBDacial I s an
<br />1615AFrSt
<br />20
<br />SaSant C J'
<br />rnVFRAr.FS PPF?TIFIrATF NI IMRFA-
<br />e a %f� a ev0 e
<br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTEET BELOW HAVE BEEN ISSUED
<br />ITO THE INSURE
<br />D NAMED ABOVE FOR THE POLICY PERIOD
<br />INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT
<br />OR OTHER
<br />DOCUMENT WITH RESPECT TO WHICH THIS
<br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE
<br />POLICIES DrSCRIBED
<br />HEREIN IS SUBJECT TO ALL THE TERMS,
<br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDt
<br />ICED BY ACCLAIMS.
<br />INSft
<br />TYPE OF INSURANCE
<br />ADOL
<br />BUSK
<br />POLICY NUMBER
<br />PO
<br />(MmuoryYyyt
<br />ICY EFF.
<br />POUCY EXP
<br />yawcoirrvYiLIMITS
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />EACH OCCURRENCE
<br />S 1,000,000,00
<br />PREMISES(Ea ott,orenee
<br />S 50,000,00
<br />CLAIMSLMDE ©OCCUR
<br />MED EXP (Any are Parson
<br />$ 10.000.00
<br />I
<br />INJURY
<br />$ 1,000,000.00
<br />A
<br />Y
<br />Y
<br />GLO-083170
<br />08/14/2023
<br />08/14/2024 1PERSONAL&ADV
<br />GENLAGGREGATE
<br />LIMIT APPLIES PER:
<br />GENERALAGORATE
<br />E 2,000,000.00
<br />JECT
<br />POUCTS- CEOPa©LOC RDCc
<br />2,000,002.2OPOUCY
<br />Self Insured retention
<br />$ 2,500
<br />OTHER:
<br />AUTOMOBILE
<br />LIABILITY
<br />COMBINED SINGLE LIMIT
<br />e I nt
<br />S 1,000,000,00
<br />ANY AUTO
<br />ODILYINJURY(Per Person)
<br />S
<br />B
<br />OWNED SCHEDULED
<br />AUTOS ONLY Auros
<br />Y
<br />Y
<br />73APBOO7393
<br />10
<br />612023
<br />10/26/2024
<br />ODILY INJURY(Pmacdden0$AUTOS
<br />ONLY AUTOS ONLY
<br />I
<br />ROPERTY DAMAGE
<br />Peraccimant
<br />$
<br />S
<br />WEBRELLA LU1e
<br />OCCUR
<br />H OCCURRENCE
<br />$ 5,000,000,00
<br />NGGREGATE
<br />$ 5,000,000,00
<br />C
<br />ace UAB
<br />CLAIMS -MADE
<br />Y
<br />Y
<br />04171616
<br />081
<br />412023
<br />08/14/2024
<br />DEO I I RETENTIONS
<br />§ 5,000,000,00
<br />WORKERS COMPENSATION
<br />PER OTH-
<br />AND EMPLOYERVLIABILITY YIN
<br />STATUTE ER
<br />. EACH ACCIDENT
<br />S
<br />ANY PROPRIETOWPARTNERIEXECUnVE
<br />OFFICEPJMEAIBER EXCLUDED'? ❑
<br />NIA
<br />Y
<br />(IndatoWln NH) 1, 'A.L.
<br />, desmbe under
<br />DISEASE -lit EMPLOYEE
<br />E
<br />.L. DISEASE - POLICY LIMIT
<br />$
<br />DESCRIPTION OF OPERATIONS bell
<br />Professional Liability
<br />A
<br />Y
<br />Y
<br />GLO-083170
<br />081
<br />4/2023
<br />08l14/2024
<br />1,000,000/1,000.0
<br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Sd edule, maybe ABa
<br />had it... span Is meulre
<br />)
<br />The below Certificate holder to be named additional Insured, City of Santa Ana, Its City Council,
<br />its officers, officials
<br />employees, agents, and
<br />volunteers are to be covered as additional Insureds With respect to liability arising out of wor
<br />or operations perfam
<br />ad by or on behalf of the
<br />Contractor Including matedals, parts, equipment, and personnel fumished in connection with
<br />such work or operatic
<br />I. Blanket Primary non Contributory
<br />wording and Blanket Waiver of Subrogation Included
<br />`30 day notice of cancellation applies.
<br />rvmnon arc un, n,-n
<br />City of Santa Ana I SHOULD ANY OF THE ABOVE
<br />20 CIVIC Center Plaza THE EXR..EEIRATION DATE T
<br />Santa Ana, CA 92701. ACCOROgNCE WITH THE POL
<br />Doug
<br />©1988-4�t3`ACbjtD C
<br />ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
<br />ID POLICIES BE CANCELLED BEFORE
<br />NOTICE WILL BE DELIVERED IN
<br />Wa4MATugmnadDhdeNn 34"
<br />�j REVIEDMED&APpROV®BY.
<br />MEW— . Risk 0.1anagement Spedaist
<br />
|