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A'C®R& CERTIFICATE OF LIABILITY INSURANCE
<br />1"i
<br />DATE(MMIDD /YYYY)
<br />1 1/21/2016
<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(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 Bolton & Company
<br />3475 E. Foothill Blvd., Suite 100
<br />Pasadena, CA 91107
<br />CONTACT
<br />NAME:
<br />PHONE FAX
<br />A/C No Ext : 626 799 -7000 A/c No : 626 583 -2117
<br />E -MAIL
<br />ADDRESS:
<br />INSURER(S) AFFORDING COVERAGE
<br />NAIC #
<br />www.boltonco.com 0008309
<br />INSURERA: Steadfast Insurance Company
<br />26387
<br />INSURED
<br />United Pumping Service, Inc.
<br />United Storm Water, Inc.
<br />INSURER 13: Zurich American Insurance Company
<br />16535
<br />INSURERC:
<br />EACH OCCURRENCE
<br />4 Lease, Inc.
<br />14000 East Valley Blvd.
<br />City of Industry CA 91746
<br />INSURER D:
<br />PREM SES (Ea occurrence)
<br />INSURER E:
<br />INSURER F
<br />$ 5,000
<br />MWWWAA-cl� -JYUCV ra.v.1urde -J- -
<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 />INSR
<br />LTR
<br />TYPE OF INSURANCE
<br />ADDL
<br />SD
<br />SUBR
<br />WVD
<br />POLICY NUMBER
<br />POLICY EFF
<br />MM /DD /YYYY
<br />POLICY EXP
<br />MM /DD/YYYY
<br />LIMITS
<br />A
<br />�/
<br />COMMERCIAL GENERAL LIABILITY
<br />CLAIMS -MADE OCCUR
<br />✓
<br />GPL008626701
<br />12/31/2015
<br />12/31/2016
<br />EACH OCCURRENCE
<br />$ 1,000,000
<br />PREM SES (Ea occurrence)
<br />$ 50,006
<br />MED EXP (Any one person)
<br />$ 5,000
<br />PERSONAL & ADV INJURY
<br />$ 1 ,000,000
<br />GEN'L AGGREGATE LIMIT APPLIES PER:
<br />POLICY ❑ PEO LOG
<br />GENERAL AGGREGATE
<br />$ 4,000,000
<br />PRODUCTS - COMP /OP AGO
<br />$ 2,600,006
<br />F
<br />$
<br />OTHER:
<br />B
<br />AUTOMOBILE
<br />LIABILITY
<br />BAP008625101
<br />12/31/2015
<br />12/31/2016
<br />MB,1NEDtSINGLELIMIT
<br />$ 1,000,000
<br />BODILY INJURY (Per person)
<br />$
<br />ANY AUTO
<br />ALL OWNED SCHEDULED
<br />AUTOS AUTOS
<br />BODILY INJURY Per accident
<br />( )
<br />$
<br />✓
<br />NON -OWNED
<br />HIRED AUTOS ✓ AUTOS
<br />PROPERTY DAMAGE
<br />Per accident
<br />$
<br />Died Comp & Collision
<br />$ 1,000
<br />A
<br />UMBRELLALIAB
<br />✓
<br />OCCUR
<br />SXS008626801
<br />12/31/2015
<br />12/31/2016
<br />EACH OCCURRENCE
<br />$ 11,000,000
<br />EXCESS LIAB
<br />CLAIMS -MADE
<br />AGGREGATE
<br />$ 11,000,000
<br />DED ✓ RETENTION $0
<br />$
<br />B
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY Y / N
<br />ANY PROPRIETOR /PARTNER /EXECUTIVE
<br />OFFICER /MEMBER EXCLUDED? ❑N
<br />NIA
<br />WC008625001
<br />12/31/2015
<br />12/31/2016
<br />PER OTH-
<br />✓ STATUTE ER
<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 />E.L. DISEASE - POLICY LIMIT
<br />$ 1,000,000
<br />DESCRIPTION OF OPERATIONS below
<br />A
<br />Pollution Liability
<br />GPL008626701
<br />12/31/2015
<br />12/31/2016
<br />1,000,000 Each Claim
<br />A
<br />Professional Liab - Claims Made
<br />GPL008626701
<br />12/31/2015
<br />12/31/2016
<br />1,000,000 Each Claim
<br />DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
<br />Re: Agreement #A-2013-114-02
<br />GL Additional Insured and Primary & Non - Contributory wording applies per STFESP101 ECW0910 attached as required by wirtten contract.
<br />Additional Insured(s): City of Santa Ana, its officers, agents, volunteers and employees.
<br />REVIEWED BY: EUNICE HEREDIA (PG OF ) ,
<br />City of Santa Ana
<br />Public Works Department
<br />20 Civic Center Plaza M -36
<br />Santa Ana, CA 92701
<br />td
<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 REPRESENTATIVE
<br />Cassandra Rosales
<br />U 19BB -2014 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
<br />28233710 1 IJNITPUM -01 1 15 -16 GL, Auto, Umb, WC, POLL, Prof Liab I Ali.. Lopez 1 1/21/2016 4:56:02 PM (PST) I Page 1 of 4
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