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AC-410RO CERTIFICATE OF LIABILITY INSURANCE
<br />DATE (MM/°DIYYYY)
<br />11/l/2016
<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 conditions 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 endorsoment(s).
<br />PRODUCER Phone: (707)996-2912
<br />Fax: (707)996-7912
<br />Apollo General Insurance Agency, Inc. (I)
<br />P. O, Box 1508
<br />CON GT Jerilee Lewis
<br />NAME:
<br />PHONE FAX
<br />No):
<br />poli ess: Jerileel@apgen.com
<br />INSURERS AFFORDING COVERAGE NAIC#
<br />Sonoma, California 95476
<br />INSURERA ; Interstate Fire & Casualty Company 22829
<br />DAN1000456
<br />INSURED
<br />INSURER 8: American Automobile Insurance Company 21849
<br />J&G Industries, Inc.
<br />INSURER C : Philadelphia Insurance Company 23850
<br />18627 Brookhurst Street
<br />INSURER D: State Compensation Insurance Fund Of California 35076
<br />PMB 302
<br />Westchester Surplus Lines Insurance Com 10172
<br />INSURER E: Company
<br />Fountain Valley, CA 92708 ®
<br />INSURER F:
<br />COVERAGES CERTIFICATE NUMBER: /u/ 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 />ILSR
<br />TYPE OF INSURANCE
<br />ADL
<br />SUER
<br />POLICY NUMBER
<br />POLICY EFF
<br />IDD/YYYY
<br />POLICY EXP
<br />MM/OD/YYYY
<br />LIMITS
<br />A
<br />COMMERCIAL GENERAL LIABILITY
<br />CLAIMS -MADE ✓� OCCUR
<br />DAN1000456
<br />Il/l/2016
<br />II/l/2017
<br />EACH OCCURRENCE $ 1,000,000
<br />PREMISES Me occurrence $ 300,000
<br />MED EXP An on$ person
<br />PERSONAL&ADV INJURY $ 1,000,000
<br />GEN'L AGGREGATE LIMIT APPLIES PER:
<br />POLICY ®JJPE LOC
<br />GENERAL AGGREGATE $ 2,000,000
<br />PRODUCTS - COMP/OP AGG $ 2,000,000
<br />$
<br />OTHER;
<br />B
<br />AUTOMOBILE
<br />LIABILITY
<br />ANY AUTO
<br />MXA30321760
<br />11/1/2016
<br />Il/l/2017
<br />EOMaBI�EeDiSINGLELI T $ 1„000,000
<br />BODILYINJURY(Perperson) $
<br />Iv
<br />OWNED SCHEDULED
<br />AUTOS ONLY AUTOS
<br />HIRED ✓ NON -OWNED
<br />AUTOS ONLY AUTOS ONLY
<br />BODILY INJURY (Per accident) $
<br />PROPERTY DAMAGE $
<br />Par acc dent
<br />C
<br />UMBRELLA LIAB
<br />EXCESS LIAB
<br />N
<br />OCCUR
<br />CLAIMS -MADE
<br />PUB562113
<br />11/1/2016
<br />Il./l/2017
<br />EACHOCCURRENCE $ 2,000,000
<br />AGGREGATE $ 2,000,000
<br />QED RETENTION $
<br />Per accident $ 2,000,000
<br />D
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY
<br />ANYPROPRIETORIPARTNER/EXECUTIVE Y❑
<br />OFFICER/MEMBEREXCLUDED?
<br />(Mandatory In NH)
<br />NIA
<br />802847-2016
<br />10/1./2016
<br />10%1/2017
<br />�/ PE OTH-
<br />T TUTS ER
<br />E,L. EACH ACCIDENT $ 1,000,000
<br />E.L. DISEASE - EA EMPLOYEE $ 1,000,000
<br />If yes describe under
<br />DESGtRIPTION OF OPERATIONS below
<br />E.L. DISEASE - POLICY LIMIT $ 1,000,000
<br />E
<br />Pollution Liability
<br />024334004005
<br />11/1/2016
<br />11/1/2017
<br />General Aggregate: 5,000,000
<br />Each Pollution Conddon: 5,000,000
<br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required)
<br />RE: Demolition Services Contract. Additional Insured coverage is included if required by written contract per
<br />endorsement hereto.
<br />LRREVIEWED BY. EUNICE HEREDIA PG OF
<br />_:z
<br />Holder's Nature of Interest; Certificate Holder
<br />City of Santa Ana Public Works Dept.
<br />20 Civic Center Plaza M-36
<br />Santa Ana, CA 92701
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />AUTHORIZED
<br />r.
<br />ACORD 26 (2016103) The ACORD name and logo are registered marks of ACORD
<br />CORPORATION. All rights reserved.
<br />
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