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ACC CERTIFICATE OF LIABILITY INSURANCE 9�ii/2o12 1 <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 O <br />IMPORTANT: If the certificate holder Is Ah'ADDITIONAL INSURED,lKe policy(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 endorsement(s). <br />PRODUCER NAME: Dona Delight <br />Hayward Tilton & Rolapp Insurance Associates, <_ PHONE , (714)905-1923 Npl.4714)90S-1910 <br />CA Dept. of Ins. Lic. #0614365 I,MAIL ADDRESS. donadQhtrinaure.com <br />888 S. Disneyland Dr., Ste 400 INSURER($) AFFORDING COVERAGE NAIC 0 <br />Anaheim CA 92802-1846 INSURERA:Travelers Indemnity Co of CT 25682 <br />INSURED asURERB:Preferred Employers Ins Cc <br />Mullen & Associates, Inc. INSURERC:U S Specialty Ins Co 29599 <br />1200 N. Jefferson Street INSURER D: <br />Suite DINSURER E : <br />Anaheim CA 92807 �'° <br />INSURER F <br />CAVFRAr:FS BFRTIFICATF NIIMRr-R•2012 GL -Aute -WC -R90 crulalnu hO iMQCD. <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 />Public Works Agency M-21 <br />20 Civic Center Plaza <br />TYPE OF INSURANCE <br />AUTHORIZED REPRESENTATIVE <br />Santa Ana, CA 92702 <br />POLICY NUMBER <br />EFF <br />MMmCY EXP <br />LIMITSGENERALLUABL <br />ITT <br />EACH OCCURRENCE $ 1,000,000 <br />S Ea ooeurronee E 300,000 <br />JA— <br />X COMMERCIAL GENERAL LIABILITY <br />CLAIMS ­MADE ROCCUR <br />6804413L748 <br />/24/2012 <br />/24/2013 <br />MED EXP (Any one person) $ 5,000 <br />PERSONAL & ADV INJURY E 1,000,000 <br />GENERAL AGGREGATE $ 2,000,000 <br />X No GL Deductible <br />GEN'L AGGREGATE LIMIT APPLIES PER <br />PRODUCTS - COMPMP AGG $ 2,000,000 <br />X POLICY PRO LOC <br />$ <br />AUTOMOBILE LMBILnYI <br />a aceiderd 11000,000 <br />BODILY INJURY (Pet Person) $ <br />A <br />ANY AUTO <br />ALLOWNED SCHEDULED <br />AUTOS AUTOS <br />X HIRED AUTOS X AUTOS ED <br />X No Dad <br />6804413L746 <br />n C <br />APPRU v L ll �S <br />/24/2012 <br />O FORM <br />/24/2013 <br />BODILY INJURY(per aedd") S <br />TY DAMAGE <br />PetaxtleM $ <br />$ <br />UMBRELLA LMB <br />EXCESS LMB <br />OCCUR <br />CLAIMS4MADE <br />_ 11• � <br />� <br />EACH OCCURRENCE $ <br />AGGREGATE $ <br />DED I I RETENTION $ <br />Wdy <br />$ <br />COMPENSATION <br />WORKB EPLOYERS LIABILITY YIN <br />AND EMPLS <br />ANY PROPRIETORIPARTNERIEXECUTIVE ff]E.L. <br />Mandan EnNHREXCLUDED7 <br />( e ) <br />n s' desaba OFundar <br />DESCRIPTION OF OPERATIONS below <br />O <br />NIA <br />-istant City <br />133245 6 <br />FKN13324S 7 <br />ttorney <br />/4/2012 <br />/4/2013 <br />/4/2013 <br />/4/2014 <br />}[ YNCSTA U- DT H <br />EACH ACCIDENT $ 11000,000 <br />E.L. DISEASE - EA EMPLOYE $ 1,000,000 <br />EE.L.DISEASE - POLICY LIMB 1 S 1 000 000 <br />C <br />Professional Liability <br />ISS1323615 <br />/4/2013 <br />/4/2014 <br />Each ClainLoR $1,000,000 <br />Retro Date: 12/28/1979 <br />ketention. $10,000 <br />aaWe0a1. $1,000,000 <br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ANach ACORD 101, Additional Remarks Schedule, N more space is roquired) <br />"Proof of Coverage" <br />Blanket Additional Insured as per CGD2520805 attached. Primary/Non-Contributory wording applies as per <br />CGD0370405 attached. <br />*CANCELLATION:10-days Notice -Non -Payment of Premium /Non -Reporting of Payroll /30 Days Notice for All <br />Other Reasons. <br />-- I -------F W -loaa-AUTU AGUKLJ L;VKPURATIVN. All rights reserved. <br />INS025 poiws).o1 The ACORD name and logo are registered marks of ACORD <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />City of Santa Ana <br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />Public Works Agency M-21 <br />20 Civic Center Plaza <br />AUTHORIZED REPRESENTATIVE <br />Santa Ana, CA 92702 <br />Dona Delight/DLD 0-.--4 <br />II <br />arrnnn ee MAdArAek <br />-- I -------F W -loaa-AUTU AGUKLJ L;VKPURATIVN. All rights reserved. <br />INS025 poiws).o1 The ACORD name and logo are registered marks of ACORD <br />