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<br />A RC7 CERTIFICATE OF LIABILITY INSURANCE
<br />DATE(MM/DD/YYYY)
<br />07/28/2016
<br />F
<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 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 endorsement(s).
<br />PRODUCER
<br />Ann Risk Services Central, Inc.
<br />Pittsburgh PA office
<br />CONTACT
<br />NAME:
<br />PHONE (866) 283-7122 FAX (800) 363-0105
<br />(A/C. No. Ext): (AIC. No.):
<br />Dominion Tower, loth Floor
<br />625 Liberty Avenue
<br />E-MAIL
<br />ADDRESS:
<br />Pittsburgh PA 15222-3110 USA
<br />INSURER(S) AFFORDING COVERAGE
<br />NAIC#
<br />INSURED
<br />INSURER A: Liberty Mutual Fire Ins Co
<br />23035
<br />Michael Baker International, Inc.
<br />BOX 57057 Ir
<br />Irvine CA 92619-7057 USA
<br />INSURER B: Liberty Insurance Corporation
<br />42404
<br />INSURER National Union Fire Ins Co of Pittsbur h
<br />9
<br />19445
<br />INSURERD: Lloyd's Syndicate No. 2623
<br />AA1128623
<br />INSURER E:
<br />INSURER F:
<br />UUVtKAUts GtRllf-IGATE NUMBER: b/UUb3226263 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. Limits shown are as requested
<br />INSR
<br />LTR
<br />TYPE OF INSURANCE
<br />ADD
<br />INSD
<br />UBR
<br />WVD
<br />POLICY NUMBER
<br />POLICY EF
<br />MMIDD/YYYY
<br />POLICY EXP
<br />MM/DD/YYYY
<br />LIMITS
<br />A
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />TB
<br />EACH OCCURRENCE
<br />$2 , 000, 000
<br />CLAIMS -MADE X OCCUR
<br />DAMAGE RENTED
<br />PREMISES Ea occurrence
<br />$1, 000, 000
<br />X
<br />MED EXP (Any one person)
<br />$ 5 , 000
<br />Contractual Liability
<br />PERSONAL &ADV INJURY
<br />$2,000,000
<br />W
<br />65
<br />GENT AGGREGATE LIMIT APPLIES PER:
<br />GENERAL AGGREGATE
<br />$4 , 000 , 000
<br />POLICY El PRO LOCcli
<br />JECT
<br />PRODUCTS - COMPlOPFlU'G
<br />$4,0001,000
<br />OTHER:
<br />0
<br />0
<br />A
<br />AUTOMOBILE LIABILITY
<br />AS2-681-004145-725
<br />08/30/2015
<br />08/30/2016
<br />COMBINED SINGLE LIMIT
<br />Ea accident
<br />$ 2 , 000 , 000
<br />BODILY INJURY ( Per person)
<br />X ANY AUTO
<br />O
<br />OWNED SCHEDULED
<br />d
<br />BODILY INJURY (Per accident)
<br />AUTOS ONLY AUTOS
<br />HIRED AUTOS NON -OWNED
<br />N
<br />p
<br />PROPERTYDAMAGE
<br />ONLY AUTOS ONLY
<br />(Per accident
<br />4=
<br />N
<br />C
<br />X
<br />UMBRELLA LIAB
<br />X
<br />OCCUR
<br />BE033086983
<br />08/30/2015
<br />08/30/2016
<br />EACH OCCURRENCE
<br />$10,000,000
<br />L)
<br />EXCESS LIAB
<br />CLAIMS -MADE
<br />AGGREGATE
<br />$10, 000, 000
<br />DED I X RETENTION$ 10, 000
<br />B
<br />WORKERS COMPENSATION AND
<br />WA768DO04145775
<br />08/30/2015
<br />08/30/2016
<br />X PER oTH-
<br />STATUTE R
<br />EMPLOYERS' LIABILITY y / N
<br />A05
<br />E.L. EACH ACCIDENT
<br />$1, 000 , 000
<br />B
<br />ANY PROPRIETOR / PARTNER / EXECUTIVE
<br />N
<br />N/A
<br />WC7681004145785
<br />08/30/2015
<br />08/30/2016
<br />OFFICER/MEMBEREXCLUDED'?
<br />(Mandatory in NH)
<br />WI
<br />E.L. DISEASE -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 />D
<br />E&O-PL-Primary
<br />QClS02675
<br />08/31/2015
<br />08/31/2016
<br />Per Claim
<br />$5,000,000
<br />Professional & Pollution
<br />Aggregate
<br />$5,000,000
<br />SIR applies per policy terns
<br />& condi t
<br />ions
<br />DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
<br />For Named Insured only: Kim Hartsfield. RE: Project Name: Agreement Numbers A-2016-093 & A-2015-170. city of Santa Ana,
<br />its officers, employees, agents and representatives are included as Additional Insured in accordance with the policy provisions
<br />of the General Liability policy. General Liability evidenced herein is Primary and Non -Contributory to other insurance
<br />available to an Additional Insured, but only in accordance the
<br />with policy's provisions. Should General Liability, Automobile
<br />Liability and workers' Compensation olicies be cancelled before the expiration date t the
<br />ere policy provisions will govern
<br />how notice of cancellation may be de ivered to certificate Holders in accordance with, h lic provisions of each policy.
<br />Y 1 4 y
<br />� REVIEWED BY � L&81`1K,E HG`REDtlA
<br />CERTIFICATE HOLDER CANCELLATION
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
<br />EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE
<br />POLICY PROVISIONS.
<br />-Fill—
<br />City of Santa Ana
<br />AUTHORIZED REPRESENTATIVE
<br />Attn: Ross Annex
<br />20 Civic Center Plaza, PO Box 1988
<br />92702-1988
<br />m;
<br />Santa Ana CA USA
<br />p
<br />©1988-2015 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
<br />
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