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DATE (MMiDDIYYYY)
<br />Ae R" CERTIFICATE OF LIABILITY INSURANCE
<br />7/27/2016
<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 poHcy(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 CONTACT Susan Remeika
<br />NAME:
<br />The Empire Company PHONE FAX
<br />(AIC, No.,.Ext) (A/C, No): ...
<br />550 North park Center Drive ADDRESSsremeika @empire- co.com
<br />SL19,.te 205 INSURER(S) AFFORDING COVERAGE NAIC #
<br />Santa Ana CA 92705 INSURER A ,Peerless Indemnity Insurance z18333
<br />INSURED INSURER B :Golden Eagle Insurance, Corporation 10836
<br />CN , L.L.C. INSURER c Employers Compensation Ins.-,Co
<br />Corbiz , LLC INSURER D
<br />P. Q, Box 10627 INSURER E: .__. __. .._.. ......_ ...... .... _...
<br />Zephyr Cove NV 89448 INSURER F ;
<br />C0VFRAGFS CERTIFICATE N'UMBER:16 /17 updated master 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
<br />TO WHICH THIS
<br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,
<br />THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL
<br />THE TERMS,
<br />EXCLUSIONS AND CONDITIONS OF SUCH POL,IUES
<br />LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
<br />INSR ADDL.9UBR
<br />LTR TYPE OF INSURANCE WV
<br />POLICY EFF POLICY IEXP
<br />POLICY NUMBER ''.... MMfODIYYYY XDD1YYYY '.... LIMITS
<br />',.. X COMMERCIAL GENERAL LIABILITY''..
<br />EACH {OCCURRENCE '. $
<br />1, 000 , 00...0
<br />.........
<br />A :. CLAIMS -MADE X OCCUR
<br />DAMAGE TO RENTED
<br />PREMISES (Ea occurrence) $
<br />100,000 ....
<br />CBP9111797 2/2.5/2016 2%25/2017 MED EXP (Anyone person) ''.. $
<br />10,000
<br />''., ''..... PERSONAL.. & AtDV INJURY $
<br />1,000,000
<br />GEN'L AGGREGATE LIMIT APPLIES PER:
<br />'.., GENERAL AGGREGATE $
<br />2,000,000
<br />X POLICY PRO-
<br />JECT LOC
<br />PRODUCTS - COMPIOP AGG $
<br />2,000,00 - 0
<br />OTHER:
<br />$.
<br />AUTOMOBILE LIABILITY
<br />..
<br />COMBINED SINGLE. LIMIT $......
<br />(Ea accident).
<br />1,000,000
<br />...
<br />ANY AUTO
<br />BODILY INJURY (Per person) $.......
<br />A _
<br />"
<br />,,....
<br />_..
<br />ALL OWNED SCHEDULED
<br />CBP6111797 ''. 2/25/2016 ... 2/25/2017 BODILY INJURY (Per accident)''. $
<br />AUTOS AUTOS
<br />X....
<br />NON -OWNED
<br />X
<br />MOPERTY DAMAGE
<br />''. $
<br />HIRED AUTOS AUTOS
<br />(Per accident)
<br />$
<br />''. X UMBRELLA LIAB '.... OCCUR
<br />'... EACH OCCURRENCE $
<br />10,000,000
<br />B EXCE5s,,,LIAB CLAIMS - MADE''..
<br />AGGREGATE __. $ _..
<br />10,000,000
<br />DED I RETENTICON$
<br />CU8112197 2/25/2016 2/25/2017 $.
<br />WORKERS COMPENSATION
<br />OTH
<br />AND EMPLOYERS' LIABILITY Y I N
<br />STATUTE
<br />'......
<br />ANY PROPRRE70RlPARTNERIEXECUTIVE
<br />'
<br />E.L. EACH ACCIDENT $
<br />1,000,000
<br />OFFICERIMEMBER EXCLUDED? NIA
<br />........
<br />..
<br />C (Mandatory in NH)
<br />EIG1721220 -03 8/1/2016 8/1/2017 E.L. USEASE - EA EMPLOYEE $
<br />1, 000, 000..
<br />If yes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />..._ ....... ._. ......
<br />''. E.L. DISEASE - POLICY LIMIT $
<br />1 000. 000...
<br />DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
<br />*30 day notice Of cancellation applies except 10 day notice for non - payment of premium,
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<br />CERTIFICATE HOLDER
<br />vwrww PuMmsM TM's ,irnc'ew .
<br />AGiron @santa- ana.org
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />City of Santa Aria, M -93 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIIVERED IN
<br />its officers, employees, agents, ACCORDANCE WITH THE POLICY PROVISIONS.
<br />and volunteers
<br />Attn: Public Works Agency AUTHORIZED REPRESENTATIVE
<br />20 Civic Center plaza
<br />Santa Ana, CA 92701 Michael Condy /SUSPAN �?�z'•< � -� �� "
<br />41988 -2014 ACORD CORPORATION, All rights reserved.
<br />ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
<br />INS025 rama01I
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