|
WKEINCO-01 ROSEM
<br />.accrrrcr° CERTIFICATE OF LIABILITY INSURANCE
<br />DAY
<br />1111212014
<br />THIS CERTIFICATE IS ISSUED ASA 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 BYTHE 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 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 Ileu of such endorsemeri
<br />PRODUCER LICOOSe'ii OE67768
<br />IDA Insurance Services -SD
<br />4350 La Jolla Villa a Drive, Suite 900
<br />2
<br />San Diego, CA 921 2
<br />CONTNAME ACT Ali Smith
<br />PHONE 619 574-6220 619 574.6288
<br />A1C No Ext: ( ) LAIC, Nor ( )
<br />EMAIL Ali.Smith@ioausa.com
<br />ADDRESS: @.
<br />INSURER(S) AFFORDI NO COVERAGE NAIC#
<br />wsURERA, RLI Insurance Company 13056
<br />INSURED
<br />MIKE, Inc.
<br />400 N. Tustin Ave., #275
<br />Santa Ana, CA 92705
<br />INSURER B: Atlantic Specialty Insurance Company 27154
<br />INSURER C:
<br />INSURER D:
<br />INSURER E
<br />NSURERF:
<br />COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
<br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED B ELOW HAVE BEEN ISSU E D TO TH E IN SU R ED NAMED ABOVE FOR TH E POLICY P ERIOD
<br />INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTH ER DOCUMENT WITH RESPECT TO WHICH TH IS
<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 CON DITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
<br />CTR
<br />TYPE OF INSURANCE
<br />AN
<br />W I
<br />POLICY NUMBER
<br />LICY EFF
<br />MMIDDHYYV
<br />POLICY EXP
<br />MMIDDIYYYY
<br />LIMITS
<br />A
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />EACH OCCURRENCE $ 2,000,000
<br />CLAIMS -MADE 1XI OCCUR
<br />X
<br />X
<br />PSB0001793
<br />10/11/2014
<br />10/11/2015
<br />PREMISES Ea occurrence $ 1,000,000
<br />X
<br />Cant Liab/Sev of I nt
<br />MED EXP (Any one parer) $ 10,000
<br />X
<br />I No Co. Owned Autos
<br />PERSONAL &ADV INJURY $ 2,000,000
<br />GEN'L AGGREGATE LIMITAPPLIES PER
<br />GENERAL AGGREGATE $ 4,000,000
<br />POLICY LX11 .PRO DLOC
<br />PRODUCTS- COMPIOPAGG $ 4,000,000
<br />Deductible $ 0
<br />OTHER:
<br />AUTOMOBILE LIABILITYiCOMBINED
<br />SINGLE LIMIT $ 2,000,000
<br />(Ed amldent
<br />BODILY INJURY (Per perSr) $
<br />A
<br />ANY AUTO
<br />X
<br />PSB0001793
<br />90/99/2094
<br />10/11/2015
<br />BODILY INJURY (Pei amldenq $
<br />ALLOWNED SCHEDULED
<br />AUTOS AUTOS
<br />PROPERTY
<br />umt)AMAG
<br />Pmdd $
<br />X X D
<br />HIREDAUTOS AUTOS
<br />_
<br />$
<br />X
<br />UMBRELLA LIAB
<br />X
<br />OCCUR
<br />EACH OCCURRENCE $ 2,000,000
<br />AGGREGATE $ 2,000,000
<br />A
<br />EXCESS LIAB
<br />CLAINI-MADE
<br />PSE0001694
<br />10/11/2014
<br />1011112015
<br />DED RETENTION$
<br />A
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS'LIABILITY
<br />ANY PROPRIETOR/PARTNERIEXF_CUTIVE YIN
<br />OFFICEMMEMBER EXCLUDED?
<br />(Mandatory In NH)
<br />RIX
<br />PSW0001614
<br />10/11/2014
<br />10/11/2015
<br />X STATUTE 10RI
<br />_
<br />E. L. EAGH ACC GENT $ 1,000,000
<br />E. L. DI SEAS E -EA EMPLOYEE $ 1,000,000
<br />Df yes, describe under
<br />ESCRIPTION OF OPERATIONS below
<br />E.L. DISEASE -POLICY LIMIT $ 1,000,000
<br />B
<br />Prof Liab/Cams Made
<br />DPL376714
<br />10/11/201410/1112015
<br />Per Claim 2,000,000
<br />B
<br />Ded.:$15k Clms Made
<br />DPL376714
<br />10/11/2014
<br />10/1112015
<br />Aggregate 2,000,000
<br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
<br />Re: Fifth Street Bridge at Santa Ana River
<br />City of Santa Ana, its officers, employees, agents, volunteers and representatives are Additional Insured's with respect to General/Hired & Non -Owned Auto
<br />Liability per the attached endorsement as required by written contract. insurance is Primary and Non -Contributory. Waiver of Subrogation applies to General
<br />Liability and Workers' Compensation.
<br />30 Days Notice of Cancellation with 10 Days Notice for Non -Payment of Premium in accordance with the policy provisions.
<br />CERTIFICATE HO "DER CANCELLATION
<br />l b °sem"' l`% 11%
<br />V, -4 r„ 7 t, .%%�
<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 />City of Santa Ana
<br />AUTHORIZED REPRESENTATIVE
<br />20 Civic Center Plaza
<br />Ross Annex (M-36)
<br />(Santa Ana, CA 92701 ,
<br />ACORD 25 (2014101)
<br />©1988-2014 ACORD CORPORATION. All rights reserved.
<br />The ACORD name and logo are registered marks of ACORD
<br />
|