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710/17/2025 <br /> E(MM/DD/YYYY) <br /> ACOR" 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 terms and conditions of the policy, certain policies may require an endorsement. A statement on <br /> this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). <br /> PRODUCER CONTACT <br /> NAME: Heidi Farman) <br /> SIP Insurance Services-Orange PHONE g51 365-3850 FAX No:626-564-6565 <br /> 790 The City Drive South, Ste 210 A/C No Ext: ( ) (Aic <br /> Orange CA 92868 ADDE-MRESS: heidif@sipbrokers.com <br /> INSURER(S)AFFORDING COVERAGE NAIC# <br /> License#:OM93299 INSURERA:Travelers Property Casualty Company of America 25674 <br /> INSURED BACKAPP-01 INSURERB:The Travelers Indemnity Company of Connecticut 25682 <br /> Backflow Apparatus&Valve Co. <br /> 20435 S. Susana Road INSURERC: <br /> Long Beach CA 90810 INSURERD: <br /> INSURER E <br /> INSURER F: <br /> COVERAGES CERTIFICATE NUMBER:1429036460 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS <br /> LTR INSD WVD POLICYNUMBER MM/DD MM/DD <br /> A X COMMERCIAL GENERAL LIABILITY Y Y 6308J664090 10/31/2025 10/31/2026 EACH OCCURRENCE $1,000,000 <br /> CLAIMS-MADE OCCUR DAMAGE TO RENTED <br /> PREMISES Ea occurrence $300,000 <br /> MED EXP(Any one person) $5,000 <br /> PERSONAL&ADV INJURY $1,000,000 <br /> GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 <br /> PRO- <br /> POLICY� ECT C LOC PRODUCTS-COMP/OP AGG $2,000,000 <br /> OTHER: $ <br /> B AUTOMOBILE LIABILITY Y Y BA7N173419 10/31/2025 10/31/2026 COMBINED SINGLE LIMIT $1,000,000 <br /> Ea accident <br /> X ANY AUTO BODILY INJURY(Per person) $ <br /> OWNED SCHEDULED BODILY INJURY(Per accident) $ <br /> AUTOS ONLY AUTOS <br /> X HIRED X NON-OWNED PROPERTY DAMAGE $ <br /> AUTOS ONLY AUTOS ONLY Per accident <br /> A X UMBRELLA LAB X OCCUR CUP9J209005 10/31/2025 10/31/2026 EACH OCCURRENCE $5,000,000 <br /> EXCESS LAB CLAIMS-MADE AGGREGATE $5,000,000 <br /> DED RETENTION$ $ <br /> A WORKERS COMPENSATION Y UB-3R155740-25-14-G 8/27/2025 8/27/2026 X PER OTH- <br /> AND EMPLOYERS'LIABILITY Y/N STATUTE ER <br /> ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 <br /> OFFICER/MEMBER EXCLUDED? ❑ N/A <br /> (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 <br /> If yes,describe under <br /> DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 <br /> A Property 6308J664090 10/31/2025 10/31/2026 Bus Personal Property Included <br /> DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) <br /> Subject to all policy terms,exclusions and conditions. <br /> RE: COSA Agreement N-2020-153;City of Santa Ana and its officers,employees,agents,volunteers and representatives all for nonprofessional related <br /> exposures are an Additional Insured with respects to the General Liability and Auto Liability if required by written contract.General Liability Additional Insured, <br /> Primary and Non-Contributory and Waiver of Subrogation endorsements attached.Auto Liability Additional Insured and Waiver of Subrogation endorsement <br /> attached.Attached Workers Compensation Waiver of Subrogation endorsement applies if required by written contract.'PLEASE NOTE COPYRIGHT LAWS <br /> APPLY TO THE ACORD FORM PROHIBITING US FROM MODIFYING THE CANCELLATION CLAUSE. HOWEVER, PER S I P INSURANCE SERVICES <br /> PROCEDURES WILL NOTIFY YOU WITHIN 30 DAYS IF SAID POLICY CANCELS. Except 10 Days Notice of Cancellation For Non-Payment Of Premium. <br /> CERTIFICATE HOLDER APPROVED CANCELLATION <br /> By Tu Tran Nguyen at 9:57 am,Oct 23,2025 <br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br /> THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br /> DigitalnyNigredby ACCORDANCE WITH THE POLICY PROVISIONS. <br /> City of Santa Ana Tu Tran <br /> Attn: Water Resources Division Date:2025.10.23 <br /> 215 S Center Street Nguyen 0957.44-07'00' AUTHORIZED REPRESENTATIVE <br /> Santa Ana CA 92703 C� // �� <br /> @ 1988-2015 ACORD CORPORATION. All rights reserved. <br /> ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD <br />