A� o® CERTIFICATE OF LIABILITY INSURANCE
<br />°A0421/20114YY)
<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 pollcy(les) 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 endoreement(s).
<br />PRODUCER
<br />Pro-Form Sinclair Professional
<br />675 Cochrane Drive
<br />NAME: Dafng Warshager
<br />- --
<br />PHONE a 1 905- 305 -1054 FAX N�O5�06 -1093
<br />No.
<br />E+4AIL
<br />ADDRESS: define .warshager @hubinterna[ional.com
<br />Suite 200, East Tower
<br />Markham, ON OR 058
<br />U5000085371-114A
<br />04/30/2014
<br />04/30/2015
<br />INSURERS AFFORDINGCOVERAGE
<br />NAICS
<br />_
<br />INSURER A:XL Insurance America, Inc. _
<br />24554
<br />INSURED
<br />IBI Group
<br />INSURER B:XL Specialty Insurance Company
<br />37865
<br />18401 Von Kerman Avenue, Suite 110
<br />INSURER C:
<br />S 5,000
<br />INSURER D:
<br />CLAIMS -MADE 7 OCCUR
<br />Irving, CA 92612
<br />INSURER E:
<br />1s t I I I of
<br />-A4J _f U7
<br />INSURER F:
<br />PERSONAL &AW INJURY
<br />COVERAGES CERTIFICATE NUMBER:PLGANRT3 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 />INTSIR TYPE OF INSURANCE
<br />L
<br />POLICY NUMBER
<br />POLICY OFF
<br />MINA YY
<br />POLICY EXP
<br />MMID
<br />LIMITS
<br />A
<br />GENERAL UAWLITY
<br />U5000085371-114A
<br />04/30/2014
<br />04/30/2015
<br />EACH OCCURRENCE
<br />s 1,000,000
<br />PREMISES Eacccurmnce
<br />S 300,000
<br />%( COMMERCIALGENERALLIABILITY
<br />MEO EXP (Any one person)
<br />S 5,000
<br />CLAIMS -MADE 7 OCCUR
<br />PERSONAL &AW INJURY
<br />$ 1,000,000
<br />X Contractual Liability
<br />GENERAL AGGREGATE _
<br />S 1,000,000
<br />GENIE AGGREGATE LIMIT APPLIES PER
<br />PRODUCTS - COMP /OP AGE
<br />S 1,000,000
<br />$ _
<br />X POLICY PRO- LOC
<br />B
<br />AUTOMOBILE UABIUTY
<br />MAGO03760402
<br />Deductible: $2,000 Camp. / $2,000
<br />04130/2014
<br />04/30/2015
<br />Ea acdtlenlSINGLE LIMIT
<br />$ 1,000,000
<br />BODILY INJURY (Per person)
<br />$
<br />X ANY AUTO
<br />Collision
<br />BODILY INJURY (Par accident)
<br />$
<br />ALL OWNED 50HEDULEO
<br />ADTOS
<br />X HIRED AUTOS X AUTOS
<br />R
<br />TO
<br />M
<br />PROPERTY
<br />$
<br />$
<br />X E2,000 Comp./
<br />$12,000 Collision
<br />UMBRELLA UM
<br />OCCUR
<br />EACH OCCURRENCE
<br />$
<br />AGGREGATE $
<br />E XCESS LIAB
<br />CLIU"_MADE1
<br />C
<br />7
<br />DED RETENTION $
<br />1
<br />$
<br />WORKERS COMPENSATION
<br />ANDEMPLOYERVLIABILITY YIN!
<br />ANY PROPRIETOR,PARTNERIE%ECUTIVE
<br />em�
<br />IeNrar aad
<br />C STATU- OTH-
<br />T W RY R
<br />I
<br />E.L. EACH ACCIDENT
<br />_
<br />S
<br />E. L. DISEASE EA EMPLOYEE
<br />$
<br />OFFICEMMEMBER EXCLUDED? ❑,NIA
<br />(Mandatory In NH)
<br />E.L. DISEASE - POLICY LIMIT
<br />$
<br />If yyeess describe under
<br />DESCRIPTION OF OPERATIONS beiov
<br />B Professional Liability Insurance
<br />DPR 9714334
<br />04130/2014 04/30/2015
<br />Each Claim
<br />Annual Aggregate
<br />1,000,000
<br />$ 1,000,000
<br />$
<br />$
<br />$
<br />DESCM"T OFOPERATIONSILOCATIONSIVEHICLES (Attach ACORD 101, Additional Remarks Schsduls, Broom 11. required)
<br />IBI Project 30866 Santa Ana General Plan Circulation Element Update
<br />'City of Santa Ana, its officers, employees, agents, volunteers and representatives" are added as additional insured to Commercial General Liability, Automobile Liability
<br />and/or Umbrella Liability only, but only with respect to liability arising out of the operations of the named Insured.
<br />The Insurer will provide the Certificate Holder with thirty (30) days written notice of cancellation of the policy.
<br />Limits shown are in US Dollars.
<br />CERTIFICATE HOLDER CANCELLATION
<br />Page l at 1 v 19aa -206 ACORD CORFORAT IVrv. All ngnis
<br />ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD
<br />SHOULD ANY OFTHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />City of Santa Ana
<br />20 CIVIC Center Place, M -20
<br />P.O. Box 1988
<br />AUTHORISED REPRESENTATIVE
<br />Santa Ana, CA 92702 -1988
<br />Page l at 1 v 19aa -206 ACORD CORFORAT IVrv. All ngnis
<br />ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD
<br />
|