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LAWRWRO-01 LHEMMERS
<br /> ,4coRo CERTIFICATE OF LIABILITY INSURANCE Dar/14/rou
<br /> 1141202x
<br /> �1 6
<br /> YYY
<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 License#0757776 CRNTACT Lysandra Jones-Hemmers
<br /> N ME:
<br /> HUB International Insurance Services Inc. PH(AI NN Eact;(909)379-1333 (arc,No1:(909)533-2266
<br /> Riverside,
<br /> Box e,C E-MAIL I sandra.hemmers hubinternatianal.com
<br /> Riverside,CA 92517 ADDRESS: y
<br /> INSURERS AFFORDING COVERAGE _ NAIC N
<br /> INSURER A:Associated Industries Insurance Company,Inc. 23140
<br /> INSURED INSURER B:American Fire and Casually Company 24066
<br /> Lawrence W. Rosine Co. INSURER C:Omaha National Casualty Company 32107
<br /> 8640 Red Oak St INSURER D:Ohio Security Insurance Company 24082
<br /> Rancho Cucamonga,CA 91730
<br /> INSURER E;.Palomar Excess and Surplus Insurance Company 16754
<br /> INSURER F
<br /> COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
<br /> THIS 1S 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 SUER POLICY NUMBER POLICY EFF POLIICDY EXPLTR LIMITS
<br /> A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
<br /> CLAIMS-MADE OCCUR X X AE51232496 02 71112025 71112026 DAMAGE
<br /> RES ESOaoccE➢ 100,000MFurrn e $
<br /> X Ded$2,500 BIIPD1PA1 MED EXP Any oneperson) $ 5,000
<br /> PERSONAL&ADV INJURY $ 1,000,000
<br /> GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
<br /> POLICY® PE LOC PRODUCTS-COMPIOP AGG $ 2,000,000
<br /> OTHER: $
<br /> B AUTOMOBILE LIABILITY COMBI NEDISINGLE LIMIT $ 1,000,000
<br /> (Fa acci enX ANYAUTO X X BAA57416003 7/112025 711/2026 BODILY INJURY Perperson) $
<br /> OWNED SCHEDULED
<br /> AUTOS ONLY AUTOS BODILY INJURY Per accident $
<br /> HIRED NON-OWNED PROPERTY AMAGE
<br /> AUTOS ONLY AUTOS ONLY Per accident $
<br /> A UMBRELLA LIAB I X IOCGUR EACH OCCURRENCE $ 5,000000
<br /> X EXCESS LIAR CLAIMS-MADE EXA1235987 02 7/1/2025 71112026 AGGREGATE $ 5,000:000
<br /> DIED I X I RETENTION$ 0
<br /> C WORKERS COMPENSATION X
<br /> AND EMPLOYERS'LIABILITY STATUTE OER
<br /> ANY PROPR.IETORIPARTNERIEXECUTIVE YIN X ONCC13081-04 7i112025 7/112026 1,000,000
<br /> ppFFICERIMEMBER EXCLUDED? ® N l A E.L.EACH ACCIDENT $
<br /> (MandatoryinNH} E..L.DISEASE-EA EMPLOYEE $ 1,000,000
<br /> IF yesescrlbe under 1,000,000
<br /> EndDRIPTION OF OPERATIONS below E.L.➢ISEASE-POUCY LIMIT $
<br /> D IlnstallllnlandMarine BKS57416003 711/2025 7/112026 Any 1 Location 250,000
<br /> E Excess Liab over$5m PES-XS-01-5868 7/112025 71112026 Each OccurrencelAgg 5,000,000
<br /> DESCRIPTION OF OPERATIONS I LOCATIONS(VEHICLES (ACORD 1 D1,Additional Remarks Schedule,may be attached if more space is required}
<br /> Re: LWR,fob#8005 Santa Ana City Hall—4th Floor Tenant Improvements Project 22-0502
<br /> City of Santa Ana is Additional insured on.General Liability including Primary/Non-Contributory and Waiver of Subrogation,as required by written contract
<br /> per attached. Auto Additional Insured,Waiver of Subrogation,and Primary wording applies per attached. Waiver of Subrogation on Workers Compensation
<br /> applies per attached. Excess Liability follows form to underlying General Liability,Automobile and Employer's Liability(Workers Compensation).
<br /> Commercial Excess Liability of$5,000,000 applies over the$5,000,000 Primary Excess Liability.
<br /> Tu Tran Dlgltallysignedby
<br /> Tu Fran Nguyen
<br /> Nguyen °3 z,°�a ° APPROVED
<br /> CERTIFICATE HOLDER CANCELLATION By Tu Tran Nguyen at 1 01 pm,Jan 14,2026
<br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br /> City of Santa Ana THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br /> y ACCORDANCE WITH THE POLICY PROVISIONS.
<br /> 20 Civic Center Plaza
<br /> Santa Ana,CA 92701
<br /> AUTHORIZED
<br /> REPRESENTATIVE
<br /> ACORD 25(2016/03) O 1988-2015 ACORD CORPORATION. All rights reserved.
<br /> The ACORD name and logo are registered marks of ACORD
<br />
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