|
CERTIFICATE OF LIABILITY INSURANCE
<br />(MMIDDrcvvv)
<br />3/119/29/2013
<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 INSURAN¢ [ ®O �.QNQ , fflTTUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
<br />REPRESENTATIVE OR PRODUCER, AND THE CERi �I�A O E '
<br />IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to
<br />the terms and conditions of the policy, certain OcIllicles may roc 1-0 an endorsement. A statement on this certificate does not confer rights to the
<br />certificate holder in lieu of such endorseme .�.'(7 ,.. = I, AA
<br />A -
<br />PRODUCER az.., �`ii ;dl .. ,
<br />Van Gilder Insurance Corp.
<br />1515 Wynkoop, Suite 200
<br />0 _ 20 J ph 1
<br />Denver CO 80202 N V UV
<br />.NAME: Star
<br />PHONE 3 - AICNO:
<br />E- AIL
<br />ss,kstardyclic.corn
<br />ic.ca
<br />INSURERS AFFORDING COVERAGE
<br />NAIC4
<br />��
<br />INSURERAAL Specialty In
<br />GENERAL LIABILITY
<br />Y
<br />INSURED INTCON6
<br />INSURER B: '
<br />11/1412012
<br />INSURER C:PL-Travelers Indemnity Co of C
<br />EACH OCCURRENCE
<br />Intefwest Consulting Group
<br />Naffa, Inc.
<br />1076 Lincoln Place
<br />INSURER D:
<br />$1,000,000
<br />INSURERS
<br />X COMMERCIAL GENERAL LIABILITY
<br />CLAIMS -MADE OCCUR
<br />Boulder CO 80302
<br />INSURER F:
<br />COVERAGES CERTIFICATE NUMBER: 1966911231 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 />N_ SR
<br />LTR
<br />WPEOF INSURANCE
<br />INSR
<br />MD
<br />POLICYNUMBER
<br />POLICY EFF
<br />MMIDDIYYYY
<br />POLICY EXP
<br />MMIDDFYVY
<br />LIMITS
<br />B
<br />GENERAL LIABILITY
<br />Y
<br />Y
<br />6807460MB71
<br />11/1412012
<br />1114/2013
<br />EACH OCCURRENCE
<br />$2,000,000
<br />TO RENT'
<br />PREMISES Ea owurMo.)
<br />$1,000,000
<br />X COMMERCIAL GENERAL LIABILITY
<br />CLAIMS -MADE OCCUR
<br />MED EXP(Any one person)
<br />$10,000
<br />PERSONAL &ADV INJURY
<br />$2,000,000
<br />GENERAL AGGREGATE
<br />$4,000,000
<br />GEN'L AGGREGATE LIMIT APPLIES PER
<br />PRODUCTS - COMP /OPAGG
<br />$4,000,000
<br />POLICY X PRO- LOC
<br />JECT
<br />$
<br />C
<br />AUTOMOBILE
<br />LIABILITY
<br />Y
<br />Y
<br />BA7466M429
<br />11/1412012
<br />1/14/2013
<br />Ea eccltlent
<br />1000000
<br />BODILY INJURY(Per person)
<br />$
<br />X
<br />ANYAUTO
<br />ALL OWNED SCHEDULED
<br />AUTOS AUTOS
<br />BODILY INJURY Per emident
<br />( 1
<br />$
<br />X
<br />HIRED AUTOS X AUTO-0WNEO
<br />PeOa�IRTYaDAMAGE
<br />$
<br />B
<br />X
<br />UMBRELLAUAB
<br />X
<br />OCCUR
<br />Y
<br />Y
<br />CUP133OT362
<br />11114/2012
<br />1/14/2013
<br />EACH OCCURRENCE
<br />$1,000,000
<br />EXCESS LIAB
<br />CLAIMS -MADE
<br />AGGREGATE
<br />$11000,000
<br />DED X I RETENTION$ 10,000
<br />$
<br />g
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY YIN
<br />ANY PROPRIETOR /PARTNER /EXECUTIVE E
<br />OFFICERIMEMBER EXCLUDED?
<br />NIA
<br />Y
<br />VMPIUB133IT93411
<br />11/14/2012
<br />1/14/2013
<br />X NGSU- OTH-
<br />V LI TAT
<br />E.L. EACH ACCIDENT
<br />$1,000,000
<br />E.L. DISEASE - EA EMPLOYEE
<br />$1,000,000
<br />(Mandatory In NH)
<br />If yes, describe under
<br />DE SCRIPTION OF OPERATIONS below
<br />E.L, DISEASE - POLICY LIMIT
<br />$1,000,000
<br />A
<br />Professlonal Liability
<br />Claims Made
<br />Fenno Date; 6/112002
<br />DPR9703316
<br />11/14/2012
<br />1111412013
<br />Per Claim $1,000,000
<br />Annual Aggregate $3,000,000
<br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
<br />As required by written contract or written agreement, the following provisions apply subject to the policy terms, conditions, limitations and
<br />exclusions: The Certificate Holder is included as Additional Insured for your work, acts or omissions which includes completed operations
<br />under General Liability; Designated Insured under Automobile Liability; and Additional Insured under Umbrella / Excess Liability but only with
<br />respell to liability arising out of the Named Insured's work performed on behalf of the certificate holder and owner. This insurance will apply
<br />on a primary and non- contributory basis, A Blanket Waiver of Subrogation applies for General Liability, Automobile Liability, Umbrella /Excess
<br />Liability Workers Compensation.
<br />and The Umbrella / Excess Liability provides excess coverage over the General Liability, Automobile
<br />Liability and Employers Liability. AP�'�..S.::D VL.D AS TIC k''lJRM
<br />O � L.,aura
<br />City of Santa Ana Assistant
<br />PO Box 1988
<br />Santa Ana CA 92701
<br />T�— "'_ - - -- SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />i cedy THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />Attorney ACCORDANCE WITH THE POLICY PROVISIONS.
<br />AUTHORIZED REPRESENTATIVE
<br />© 1988 -2010 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD
<br />
|