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<br />A ,.. CERTIFICATE OF LIABILITY INSURANCE
<br />DATE (MM/DD/YYYY)
<br />2/8/2017
<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 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
<br />CONTACT Sue Reams
<br />NAME:
<br />PHC NNo Ext): (714) 905-1923 1A/c No): (714)905-1910
<br />Hayward Tilton & Rolapp Insurance Associates, Inc.
<br />CA Dept. of Ins. Lic. #0614365
<br />ADDRIESS:suer@htrinsure.com
<br />888 S. Disneyland Dr., Ste 400
<br />INSURER(S) AFFORDING COVERAGE NAIC #
<br />—
<br />INSURERA:Travelers Indemnity Company 25658
<br />Anaheim CA 92802-1846
<br />---------- --- .... _........ . - ------ ._.__.._._..._._..--
<br />INSURED
<br />INSURER B:Preferred Employers Ins Co
<br />Mullen & Associates, Inc.
<br />INSURERC:U S Specialty --Ins-Co--- 29599
<br />INSURER D:
<br />1200 N. Jefferson Street Suite D
<br />INSURER E:
<br />Anaheim, CA 92807
<br />INSURER F:
<br />COVERAGES CERTIFICATE NUMBER:16-17 All Lines 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 />INSR7AN
<br />LTR
<br />TYPE OF INSURANCE
<br />DLTSUBR
<br />(( WVD
<br />POLICY NUMBER
<br />POLICY EFF
<br />MM/DD/YYYY
<br />POLICY EXP
<br />MM/DD/YYYY
<br />LIMITS
<br />X I COMMERCIAL GENERAL LIABILITY
<br />EACH OCCURRENCE
<br />$ 1,000,000
<br />A
<br />CLAIMS -MADE A] OCCUR
<br />DAMAGES(TO RENTED
<br />PREMISES Ea occurrence
<br />$ 300,000
<br />MED EXP (Any one person)
<br />$ 5,000
<br />X
<br />6802D291163
<br />X Deductible 0
<br />PERSONAL &ADV INJURY
<br />$ 1,000,000
<br />GEN'LAGGREGATE LIMIT APPLIES PER:
<br />07/24/2016
<br />07/24/2017
<br />GENERAL AGGREGATE
<br />$ 2,000,000
<br />POLICYFX - JECT CJ LOC
<br />PRODUCTS -COMP/OP AGG
<br />$ 2,000,000
<br />Non -owned
<br />$ included
<br />OTHER:
<br />AUTOMOBILE
<br />LIABILITY
<br />COMBINED SINGLE LIMIT
<br />Ea accident
<br />$ 1,000,000
<br />BODILY INJURY (Per person)
<br />$
<br />ANY AUTO
<br />ALL OWNED SCHEDULED
<br />AUTOS AUTOS
<br />6802D291163
<br />BODILY INJURY (Per accident)
<br />$
<br />A
<br />x
<br />HIRED AUTOS 7{ NON -OWNED
<br />AUTOS
<br />07/24/2016
<br />07/24/2017
<br />PROPERTY DAMAGE
<br />Per accident
<br />$
<br />Deductible 0
<br />$
<br />— UMBRELLA LIAB OCCUR
<br />EACH OCCURRENCE
<br />$
<br />EXCESS LIAB CLAIM _
<br />-- -- RF.VNEt!1fCk�
<br />BY:
<br />F4.B6"�@c L
<br />F9ECHEIJd�� (F"C
<br />I (,.)F-
<br />AGGREGATE
<br />$
<br />$
<br />DEDRETENTION $.—..___._
<br />.._.._._r...�.....
<br />_._._.....__, .-. .-...._.___.___.._......_
<br />�.__._.____.._._.r�_..._._.
<br />_._
<br />WORKERS COMPENSATION
<br />X PEROTH-
<br />AND EMPLOYERS' LIABILITY YIN
<br />STATUTE ER
<br />-
<br />ANY PROPRIETOR/PARTNER/EXECUTIVE
<br />OFFICER/MEMBER EXCLUDED?
<br />N / A
<br />E.L. EACH ACCIDENT
<br />------------------
<br />$ 1,000,000
<br />B
<br />(Mandatory in NH)
<br />WKN13324511
<br />2/4/2017
<br />2/4/2018
<br />E.L. DISEASE - EA EMPLOYE
<br />$ 1,000,000
<br />If yes, describe under
<br />-------------------------
<br />DESCRIPTION OF OPERATIONS below
<br />E.L. DISEASE -POLICY LIMIT
<br />$ 1,000,000
<br />C
<br />Professional Liablity
<br />USS1727323
<br />1/4/2017
<br />1/4/2018
<br />Each Claim Limit $1,000,000
<br />Errors & Omissions7I
<br />1
<br />1
<br />Aggregate Dart $10,000 $1,000,000
<br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
<br />Agreement # A-2014-087
<br />City of Santa Ana, 20 Civic Center Plaza, Santa Ana, CA 92701, its officers, employees, agents,
<br />volunteers and representatives are named as additional insured with regard to general liability & arising
<br />from the operations and uses performed by or on behalf of the named insured per policy form CG D3 81 09
<br />07, Primary and Non Contributory Wording apply per form CG D0370405.
<br />*CANCELLATION:10-days Notice for Non -Payment of Premium/Non-Reporting of Payroll/30 days for all other
<br />reasons.
<br />mboothe@santa-ana.org
<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 />Public Works Agency ACCORDANCE WITH THE POLICY PROVISIONS.
<br />20 Civic Center Plaza, 3r Flr,
<br />ROSS Annex AUTHORIZED REPRESENTATIVE
<br />Santa Ana, CA 92701
<br />Gloria Zimmerman/GJZ �-------'-
<br />©1988-2014 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
<br />INS025 nmanrn
<br />
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