|
DATE(MM/DD/YYYY)
<br /> A�" CERTIFICATE OF LIABILITY INSURANCE
<br /> 10/03/2025
<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 CONTACT
<br /> NAME:
<br /> FOY and Associates PHONE FAX
<br /> A/C No Ext: A/C,No):
<br /> 21300 Victory Blvd,Suite 700 E-MAIL linda.gozal@grosslight.com
<br /> ADDRESS:
<br /> INSURER(S)AFFORDING COVERAGE NAIC#
<br /> Woodland Hills CA 91367 INSURERA: Citizens Insurance Company ofAmerica 31534
<br /> INSURED INSURER B: Allmerica Financial Benefit Insurance Company 41840
<br /> Transportation Studies,Inc. INSURER C: United States Liability Insurance Company 25895
<br /> 2640 Walnut Avenue,Suite H INSURER D:
<br /> INSURER E:
<br /> Tustin CA 92780 INSURER F:
<br /> COVERAGES CERTIFICATE NUMBER: CL2510222484 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
<br /> CERTIFICATE MAYBE 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 POLICY EFF POLICY EXP
<br /> LTR INSD WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS
<br /> X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
<br /> CLAIMS-MADE FX OCCUR PREM SDAMAGES Ea oNcurDrence $ 500,000
<br /> MED EXP(Any one person) $ 10,000
<br /> A Y Y OB3J56288304 10/01/2025 10/01/2026 PERSONAL&ADV INJURY $ 1,000,000
<br /> GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000
<br /> X POLICY ❑ PRO ❑ LOC PRODUCTS-COMP/OPAGG $ 2,000,000
<br /> JECT
<br /> OTHER: $
<br /> AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000
<br /> Ea accident
<br /> X ANYAUTO BODILY INJURY(Per person) $
<br /> B OWNED SCHEDULED AW3J56287303 10/01/2025 10/01/2026 BODI LY I NJ U RY(Pe r accide nt) $
<br /> AUTOS ONLY AUTOS
<br /> HIRED NON-OWNED PROPERTY DAMAGE $
<br /> AUTOS ONLY AUTOS ONLY Per accident
<br /> X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000
<br /> A EXCESS LAB CLAIMS-MADE OB3J56288304 10/01/2025 10/01/2026 AGGREGATE $ 2,000,000
<br /> DED I X1 RETENTION $ O $
<br /> WORKERS COMPENSATION X STATUTE EORH
<br /> AND EMPLOYERS'LIABI LI TY YIN 1,000,000
<br /> ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $
<br /> B OFFICER/MEMBER EXCLUDED? N/A WD3J56288205 10/01/2025 10/01/2026
<br /> (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000
<br /> If yes,describe under 1,000,000
<br /> DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
<br /> Errors and Omissions Aggregate $2,000,000
<br /> C SP025LO495 10/01/2025 10/01/2026 Each Occurrence $1,000,000
<br /> Retention $1,000
<br /> DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
<br /> City of Santa Ana,its City Council,officers,officials,employees,agents,and volunteers are named as Additional Insured with respect to General Liability as
<br /> their interests may appear subject to the conditions,limitations and exclusions of the policy forms.Waiver of subrogation applies.
<br /> Digitally signed by
<br /> Tu Tran
<br /> Tu Tran Nguyen
<br /> Nguyen 125;510;00' APPROVED
<br /> CERTIFICATE HOLDER CANCELLATION By Tu Tran Nguyen at 12:51 pm,Oct 27,2025
<br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br /> THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
<br /> City of Santa Ana ACCORDANCE WITH THE POLICY PROVISIONS.
<br /> Attn:PWA-Traffic Engineering
<br /> AUTHORIZED REPRESENTATIVE
<br /> 20 Civic Center Plaza,M-43
<br /> Santa Ana CA 92701 oz
<br /> @ 1988-2015 ACORD CORPORATION. All rights reserved.
<br /> ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
<br />
|