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1 ® <br />A� o CERTIFICATE OF LIABILITY INSURANCE <br />DATE(MMIOD/YVYY) <br />oe/za/zgz4 <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. If <br />SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this <br />certificate does not confer rights to the certificate holder in lieu of such endorsement(s). <br />PRODUCER <br />AOn R15k services Northeast, Inc. <br />New York NY Office <br />CONTACT <br />NAME: <br />PHONE (g66 283-7122 FAX (800) 3 -To <br />(NC. No. Ex �: No.: OS <br />One Liberty Plaza Li <br />165 Broadway, Suite 3201 <br />r^1 <br />EMAIL IC I M <br />ADDRESS: _ <br />CA/C. <br />signed <br />New York NY 10006 USA <br />lSURER(S)#FFOR01 GCOVERAGE <br />NAIC# <br />INSURER A: 51 r elvedo <br />33600 <br />eles SMSA LP <br />izon wireless enue of the AmeriA <br />42404 <br />INSURERr '.iberty surance corporation <br />INSUREF C: <br />rt�y.�A >1 <br />23035 <br />k NY 10036 usA <br />[ba <br />d <br />suR• a D: <br />Q ` <br />I I IER E: <br />c e v e <br />UREfl F: <br />COVERAGES CERTIFICATE NUMBER: 570107777P: 0 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. Limits shown are as requested <br />INSR <br />LTR <br />TYPE OF INSURANCE <br />Mon <br />INSD <br />SUSHI <br />WVD <br />POLICY NUMBER <br />MM/OCIY <br />EAR <br />MMB)C <br />LIMITS <br />CPOLICY <br />X <br />COMMERCIAL GENERAL LIABILITY <br />TS <br />EACH OCCURRENCE <br />$2,000,000 <br />CLAIMSMADE ❑X OCCUR <br />PREMISES Ea oxurmnca <br />$2,000,000 <br />X <br />MED EXP (Any one person) <br />$10, 000 <br />XCU Coverage is Included <br />PERSONAL& ADV INJURY <br />$2,000,005 <br />GEN'L AGGREGATE LIMIT APPLIES PER: <br />X POLICY ❑JE o- LOC <br />GENERALAGGREGATE <br />$5,000,000 <br />PRODUCTS - COMP/OPAGG <br />$5,000,000 <br />OTHER: <br />C <br />AUTOMOBILE LIABILITY <br />A52-691-550588-124 <br />A05 <br />06/30/2024 <br />06/30/202 5 <br />COMBINED SINGLE LIMIT <br />Ea awidentl <br />$1,000,000 <br />BODILY INJURY (Pay person) <br />C <br />X ANYAUTO <br />AS2-691-550588-134 <br />06/30/2024 <br />06/30/2025 <br />C <br />OWNED SCHEDULED <br />AUTOS ONLY AUTOS ONLY AUTOS <br />HIREDAUTOS NON OWNED <br />ONLY <br />NH - Primary <br />TL2-691-550588-184 <br />NH - Excess <br />06/30/2024 <br />06/30/2025 <br />BODILY INJURY (Per acdtlen0 <br />PROPERTY DAMAGE <br />Per acdtlent <br />UMBRELLA LIM <br />OCCUR <br />EACH OCCURRENCE <br />EXCESS LIM <br />CLAIMS MADE <br />AGGREGATE <br />DEO <br />RETENTION <br />A <br />A <br />WORKERS COMPENSATIONAND <br />EMPLOYERS'LIABILITY Y/N <br />ANY PROPRIETOR/PARTNER/EXECUTIVE <br />OFFICERIMEMBER EXCLUDED? <br />(Mandatory In NN) <br />If yes. descdbe under <br />DESCRIPTION OF OPERATIONS below <br />NIA <br />WAS69DS50588094 <br />ADS <br />WC5691550588084 <br />WI, MN <br />06/30/2024 <br />06/30/2024 <br />06/30/2025 <br />06/30/2025 <br />X PER STATUTE OTH- <br />R <br />E.L. EACHACCIDENT <br />$1,000,000 <br />E.L. DISEASE -EA EMPLOYEE <br />$1,000,000 <br />E.L. DISEASE -POLICY LIMB <br />$1, 000, 000 <br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be aNacbed N more space Is remained) <br />The above -referenced General Liability policy shall cover the tort liability of the certificate Holder assumed under the <br />underlying agreement between parties for which the certificate has been issued. RE: Project Number: A-2020-047. City of <br />Santa Ana, its council members, officers and employees are included as Additional insured with respect to the General Liability <br />policy. The General Liability policy shall apply as Primary Insurance & Non-contributory Insurance to each Additional insured <br />listed herein. Where permitted by law, the Named Insured parties listed herein waive all rights against City of Santa Ana, its <br />council members, officers and employees listed herein for recovery damages to the damages by <br />of extent these are covered the <br />above -referenced General Liability policy and, as further limited by written contract between the parties. <br />CERTIFICATE HOLDER CANCELLATION <br />City of Santa Ana <br />20 Civic Center Plaza <br />Santa Ana CA 92701 USA <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE <br />EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE <br />POLICY PROVISIONS. <br />AUTHORIZED REPRESENTATIVE <br />wo!� W� WWWWA <br />©1988-2015 ACORD CC <br />ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD <br />`u <br />_ <br />N�?c': <br />RhkMI»ugowd <br />c, BY: <br />REmEWmA� <br />�fv`wo <br />7V�vr�&APPR^QJ <br />Ro <br />'� <br />Risk Management Specialist <br />