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ACC)REII DATE{MMIDDA YYYI
<br /> CERTIFICATE OF LIABILITY INSURANCE 10/28/2025
<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(les)must have ADDITIONAL INSURED provisions or be endorsed.
<br /> If SUBROGATION IS WAIVED, subject to the terms and conditlons 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 Phone: (707)996-2912- CONTACT Jerilce Carpenter
<br /> Fax: f707)996-7912 NAME:
<br /> Apollo General Insurance Agency,Inc.(I) PHONE ac No.
<br /> P.O.Box 1509 ADDRESS: ior""C@apgen.com
<br /> Sonoma,California 95476 INSURERS AFFORDING COVERAGE NAICR
<br /> INSURERA: Nautilus Insurance Company 17370
<br /> INSURED INSURER B: Key Risk Insurance Company 10885
<br /> J&G Industries,Inc. INSURERC: State Compensation Insurance Fund Of California 35076
<br /> 18627 Brookhurst Street INSURER D t Tokio Marine America Insurance Co 10945.
<br /> PMB 302
<br /> Fountain Valley,CA 92708 INSURER E
<br /> INSURER F:
<br /> COVERAGES CERTIFICATE NUMBER:1568 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 TYPEOFINSURANCE ADOLSUBR pOLICYNUMBER M�OLICYYYY POLIIOYEXP LIMITS
<br /> LTR
<br /> ✓ COMMERCIALQENERALLIABILITY ECP2038906-13 11/1/2025 11/1/2026 EACHOCCURRENCE S 1,000,000
<br /> A CLAIMS-MADE F1 OCCUR PREMISES Ea occarrenoe $TO RENTED 100,
<br /> 000✓ Professional$1,000,000 t/ MED EXP W one rson) S
<br /> PERSONAL&ADV INJURY S 1,000,000
<br /> GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
<br /> POLICY®jE� El LOG PRODUCTS-COMPIOPAGG S 2,000,000
<br /> OTHER: $
<br /> AUTOMOBILELLABILITY BAP2041776.12 11/1/2025 t 1/1/2026 COMBINED SINGLELIMIT $ 1,000,OOD
<br /> B —
<br /> ANY AUTO BODILY INJURY{Per person)
<br /> OWNED ✓ SCHWULEO BODILY INJURY(Per accident) $
<br /> AUTOSONLY AUTOS ✓
<br /> HIRED �/ NON-OWNED PROPERTY DAMAGE S
<br /> AUTOS ONLY AUTOS ONLY Per accident
<br /> S
<br /> UMIIR12LLAIIAB N OCCUR FFX2038907-13 11/1/2025 Il/1/2026 EACH OCCURRENCE $ 5,000,000
<br /> A ✓ EXCESSLIA8
<br /> CLAIMS-MADE AGGREGATE $ 5,000,000
<br /> DED I I RETENTIONS $
<br /> WORKERS COMPENSATION ✓ PERC AND EMPLOYERS'LIABILITY 9346759-25 10/1/2025 l0/1/2026 STATUTE ER"-
<br /> ANYPROPRIETORIPARTNER/EXECUTIVE YIN NIA E.L.EACH ACCIDENT S 1,000,000
<br /> OFFICERIMEMSEREXCLUDED7
<br /> (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S 1,Q00,000
<br /> It es,describe under 1,000,000
<br /> DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S
<br /> D Inland Marine(Commercial) '� CPP6412447-01 11/1/2025 11/1/2026 Rmtedlleaud:Per Item 750,000
<br /> Rentedff- ed.PerOccwrmee 750,00
<br /> DESCRtPTION OF OPERA'nONS1 LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached If more apace Is requlred)Continued on Attached Supplement.
<br /> Re: "Demolition Services on an on-Call basis Agreement: A-2022-065-01". Operations of the Named Insured. City of
<br /> Santa Ana, its officers, officials, employees, and volunteers are hereby named as Additional Insured, if required by
<br /> written contract, per endorsement hereto. Waiver of Subrogation is provided, as required by written contract with the
<br /> insured as respects coverage evidenced herein. Coverage evidenced herein is primary and non-contributory. Excess
<br /> (schedule of controlling underlying insurance attached) is follow form to the underlying General Liability,
<br /> Commercial Auto and Workers Compensation Coverage. A 30-day written notice shall be mailed to the certificate holder
<br /> at the address provided herein, should a described policy($) be cancelled before the expiration date thereof, 10--day
<br /> CERTIFICATE HOLDER CANCELLATION
<br /> Holder's Nature oflnierest:Additional insured
<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 /> ACCORDANCE WITH THE POLICY PROVISIONS.
<br /> Attention: Public Works Agency
<br /> CIP/Design Engineering AUTHORIZEDREPRESZ
<br /> V E
<br /> 20 Civic Center Plaza,M-36
<br /> Santa Ana,CA 92701
<br /> WY
<br /> m 1988-2015 ACORD CORPORATION. All rights reserved.
<br /> ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD
<br /> Tu Tran °Igl[aily,;g°ed�Y [APPROVED
<br /> T�Tr Nguyen
<br /> NguyeDate:,1-0700 B TD Tran Nguyen at f 1:56 am,Oct 29,2025
<br /> n„5�,,-0�� r
<br />
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