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AC40R °® CERTIFICATE OF LIABILITY INSURANCE 06/
<br />1/20 )
<br />Page 1 of 2 0
<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 be endorsed. If SUBROGATION IS WAIVED, subject to
<br />the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
<br />certificate holder in lieu of such endorsement(s).
<br />PRODUCER CONTACT
<br />Willis Insurance Services of California, Inc.
<br />26 Centur
<br />Blvd PHONE FAX
<br />(AICNOFxT). 877-945-7378 888-467-2378
<br />y
<br />. E-MAIL
<br />P. 0. Box 305191 certificates@willis.com
<br />Nashville, TN 37230-5191
<br /> INSURER(S)AFFORDINGCoVERAGE NAIC#
<br /> INSURER& National Union Fire Ins Co of Pittsburgh 19445-100
<br />INSURED
<br />i
<br />db
<br />i
<br />i
<br />INSURER B: Zurich American Insurance Company
<br />16535-100
<br />on Amer
<br />cas
<br />URS Corporat
<br />a URS Corporat
<br />on
<br />2020 E. First Street, Suite 400 INSURERC:Illinois National Insurance Co. 23817-001
<br />Santa Ana, CA 92705
<br />INSURER D: Insurance Company of the State of PA
<br />19429-100
<br /> INSURER E: Lexington Insurance Company 19437-000
<br /> INSURER F: Lloyd's of London & British Companies 15792-004
<br />COVERAGES CERTIFICATE NUMBER: 16028973 REVISION NUMBER:See Remarks
<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 OD'L SUB POLICY NUMBER POLICY EFF POLICY EXP
<br />DOM= LIMITS
<br />A GENERAL LIABILITY ? GL4870829 5/1/2011 6/1/2012 EACH OCCURRENCE $ 2,000,000
<br /> X COMMERCIAL GENERAL LIABILITY PREMISES Eaoccurence $ 1 000 000
<br />
<br /> CLAIMS-MADE OCCUR ME D EXP (Any one person) $ 10,000
<br /> X XCU, BFPD PERSONAL SADVINJURY $ 2,000,000
<br /> X Contractual Liability GENERAL AGGREGATE $ 2,)00,000
<br /> GEN'LAGGREGATE LIMITAPPLIES PER: PRODUCTS -COMP/OPAGG $ 2 000,000
<br /> POLICY X PRO- LOC $
<br />B AUTOMOBILE LIABILITY BAP938521502 5/1/2011 6/1/2012 COMBINED SINGLE LIMIT
<br />(Ea accident)
<br />$ 2,000,000
<br /> X ANYAUTO BODILY INJURY(Per person) $
<br /> ALL OWNED
<br />AUTOS SCHEDULED
<br />AUTOS BODILY INJURY(Per accident) $
<br /> HIREDAUTOS NON-OWNED
<br />AUTOS PROPERTYDAMA E
<br />(Per accident)
<br />$
<br /> $
<br /> UMBRELLA LIAB OCCUR EACH OCCURRENCE $
<br /> EXCESS LIAB CLAIMS-MADE AGGREGATE $
<br /> DED RETENTION $ I s
<br />C WORKERS COMPENSATION
<br />' WC20635052 1/1/2011 1/1/2012 X W A u- -
<br /> AND EMPLOYERS
<br />LIABILITY
<br />Y
<br />A ANY PROPRIETOR/PARTNER/EXECUIIVE N/A WC20635051 1/1/2011 1/1/2012 E.L. EACH ACCIDENT $ 2,000,000
<br />C OFFICER/MEMBER EXCLUDED?
<br />((Mandatory. in NH) WC20635053 1/1/2011 1/1/2012 E.L. DISEASE - EA EMPLOYEE $ 2,000,000
<br />
<br />D ff yes, descnbe under
<br />DESCRIPTION OF OPERATIONS below
<br />W
<br />1/1/2011
<br />1/1/2012
<br />E.L. DISEASE - POLICY LIMIT
<br />$ 2,000,000
<br />E 015438088 5/1/2011 6/1/2012
<br />F Professional Liability PE1105150/PE1105490 5/1/2011 6/1/2012 $1,000,000 Each Claim
<br /> w/Limited Contractual - $1,000,000 Aggregate
<br /> Claims Made Policy
<br />DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach Acord 101, Additonal Remarks Schedule, if more space is required)
<br />THIS VOIDS AND REPLACES PREVIOUSLY ISSUED CERTIFICATE DATED: 5/31/2011 WITH ID: 16021742
<br />The Workers' Compensation coverage shown above does not apply in monopolistic states. In the
<br />States of ND, OH, WA and WY, Workers' Compensation coverage is provided by the State Fund. In
<br />those States, the above-referenced policies provide Stop-Gap Employers' Liability only.
<br />SEE ATTACHED
<br />CERTIFICATE HOLDER ?l 1 l?l/ V 1-ii /A,) 1 ll 1'L)ici CANCELLATION
<br />
<br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />?' ..
<br />4 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />La,Wra ht t ecdy 4 - ACCORDANCE WITH THE POLICY PROVISIONS.
<br />ASS1 t t Cl Ai(urt,,_,
<br />City of Santa Ana
<br />20 Civic Center Plaza - Rose Annex (M-36)
<br />Santa Ana, CA 92701 AUTHORIZED REPRESENTATIVE
<br />
<br />
<br />4,_-?_
<br />Coll:3376174 Tpl:1261289 Cert:16028973 ©1988-2010 ACORDICORPORATION. All rights reserved.
<br />ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD
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