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A�--�C 1 �®
<br />V � CERTIFICATE OF LIABILITY INSURANCE
<br />DATE IYYYY)
<br />03/27/20257/2025
<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
<br />CONTACT
<br />NAME:
<br />MARSH RISK & INSURANCE SERVICES
<br />PHONE FAX
<br />FOUR EMBARCADERO CENTER, SUITE 1100(A/C,
<br />No Ext : A/C, No):
<br />E-MAIL
<br />CALIFORNIA LICENSE NO. 0437153
<br />SAN FRANCISCO, CA 94111
<br />ADDRESS:
<br />INSURER(S) AFFORDING COVERAGE
<br />NAIC #
<br />INSURERA: Safety National Casualty Corp.
<br />15105
<br />CN 101 483686-SCAL-CAS-25-26 GLALW CA
<br />INSURED
<br />KAISER FOUNDATION HEALTH PLAN, INC.
<br />INSURER B :
<br />INSURER C :
<br />KAISER FOUNDATION HOSPITALS
<br />393 EAST WALNUT STREET
<br />PASADENA, CA 91188
<br />INSURER D
<br />INSURER E
<br />INSURER F :
<br />COVERAGES CERTIFICATE NUMBER: SEA-003811693-15 REVISION NUMBER: 8
<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
<br />LTR
<br />OF INSURANCE
<br />ADDLSUBRTYPE
<br />INSD
<br />WVD
<br />POLICY NUMBER
<br />POLICY EFF
<br />MM/DDIYYYYI
<br />POLICY EXP
<br />iMMIDDIYYYYI
<br />LIMITS
<br />A
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />GL4048017
<br />01/01/2025
<br />01/01/2026
<br />EACH OCCURRENCE
<br />$ 5,000,000
<br />CLAIMS -MADE X� OCCUR
<br />RENTEDDAMAGE TO
<br />FIR SES(E..";
<br />Ea occrre...
<br />$ 5,000,000
<br />MED EXP (Any one person)
<br />$ 10,000
<br />PERSONAL & ADV INJURY
<br />$ 5,000,000
<br />GEN'L
<br />AGGREGATE LIMIT APPLIES PER:
<br />GENERAL AGGREGATE
<br />$ 5,000,000
<br />POLICY ❑ PRO ❑ LOC
<br />JECT
<br />X
<br />PRODUCTS-COMP/OPAGG
<br />$ 5,000,000
<br />$
<br />OTHER:
<br />A
<br />AUTOMOBILE LIABILITY
<br />CA6675880
<br />01/01/2025
<br />01/01/2026
<br />COMBINED SINGLE LIMIT
<br />Ea accident
<br />$ 4,000,000
<br />BODILY INJURY (Per person)
<br />$
<br />A
<br />X ANY AUTO
<br />$1,000,000 SIR
<br />OWNED SCHEDULED
<br />AUTOS ONLY AUTOS
<br />BODILY INJURY (Per accident)
<br />$
<br />PROPERTYDAMAGE
<br />Per accident
<br />$
<br />HIRED NON -OWNED
<br />AUTOS ONLY AUTOS ONLY
<br />L
<br />$
<br />UMBRELLALIAB
<br />OCCUR
<br />EACH OCCURRENCE
<br />$
<br />AGGREGATE
<br />$
<br />EXCESS LIAB
<br />CLAIMS -MADE
<br />DED RETENTION $
<br />$
<br />A
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY Y / N
<br />ANYPROPRIETOR/PARTNER/EXECUTIVE
<br />OFFICER/MEMBER EXCLUDED? N❑
<br />(Mandatory in NH)
<br />NIA
<br />SP4067916
<br />S.I.R. $5,000,000
<br />01/01/2025
<br />01/01/2026
<br />PER OTH-
<br />X STATUTE ER
<br />E.L. EACH ACCIDENT
<br />$ 5,000,000
<br />E.L. DISEASE - EA EMPLOYEE
<br />$ 5,000,000
<br />If yes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />E.L. DISEASE - POLICY LIMIT
<br />$ 5,000,000
<br />DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
<br />REQUEST #RC010620
<br />THE CITY OF SANTA ANA, ITS OFFICERS, OFFICIALS, EMPLOYEES AND VOLUNTEERS ARE INCLUDED AS ADDITIONAL INSURED AS RESPECTS GENERAL LIABILITY TO THE EXTENT REQUIRED
<br />BY WRITTEN CONTRACT. THE GENERAL LIABILITY POLICY IS PRIMARY AND NON-CONTRIBUTORY WHERE REQUIRED BY WRITTEN CONTRACT. POLICIES INCLUDE A WAIVER OF
<br />SUBROGATION WHERE REQUIRED BY WRITTEN CONTRACT AND ALLOWED BY LAW.
<br />Digitallysigned....................................................................................................................................................... ,
<br />Tu Train by Tu Tran
<br />Nguyen APPROVED
<br />I�
<br />N Q U ven Date: 2025.03.27
<br />_ 8`k..... Y...'K"umw.. MB—..a...d.,.e....n ..r A—C&". , — AA .'17
<br />CERTIFICATE HOLDER
<br />CITY OF SANTA ANA
<br />20 CIVIC CENTER PLAZA
<br />SANTA ANA, CA 92701
<br />CANCELLATION.. � . K aap� m m a�,r�:aVGGIN , �
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />AUTHORIZED REPRESENTATIVE
<br />of Marsh Risk & Insurance Services
<br />© 1988-2016 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
<br />
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