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<br />AlC"C D CERTIFICATE OF LIABILITY INSURANCE DATE{MMrDDIYYYYI
<br />Irv,.,..• -' 11)1/2016 1(?124 2415
<br />THIS CERTIFICATE I$ 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 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 INS Certificate, does not confer rights to the
<br />51Ia NaH1t1
<br />444 W. 471h Steect, Suite 900
<br />Kansas City MO 64T 12 -1906
<br />(816) 960 -9000
<br />INSURED BLACK & VEATC11 CORPORATION
<br />1058332 11401 LAMAR
<br />OVERLAND PARK KS 66211
<br />Bui, Ann
<br />COVERAGES RT.AVB01 CERTIFICATE NUMBER- 11 iF770R RFVISInN MHUFRFR. YYYVVVV
<br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PER500
<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 />IN3a AD TI SITa"k ... —�'�� P0.` ICh":FF POLICY
<br />LTR TYPE OFdNBURANCE POLICY NUMBER MMaJ 2 iMMIDDNYYY) LIMIT$
<br />•
<br />Y.
<br />COMMERCIAL GENERAL LIABILITY Y
<br />N OL04641358 v 11/1015 11/11201.6
<br />EACH OCCURRENCE $ 1,000,000
<br />15'XftA"GE70 RENTED
<br />A
<br />CLAIMS -MADE OLiGDR
<br />GL,.04fi41367 PPl1 /2015 11/1201.6
<br />R• <ES E. &q. $ 300,000,_
<br />•
<br />X
<br />CONTRACTUAL ....�..,,
<br />GT- 001179245 11112U15 II /YfZ016
<br />MEDEXP(An one person] _% ]0,000
<br />,X.
<br />I�'1I''pD BL t.'lQ &X01
<br />PERSONAL &ADV INJURY S 1,000,000
<br />GENERAL AGGREGA7= 3 2,000 000_
<br />GEML
<br />AGGREGATE LIMIT APPLIES PER:
<br />�
<br />POLICY 0 PrOT LOU
<br />PRODUCTS_COMPtOF AGV $ 1000000 —
<br />OTHER:
<br />$
<br />•
<br />AUTOMOBILE LIABILITY 1N
<br />N RAP4641355 AOS I1 /I. /20H5 I1/1 /2016
<br />CO' IN DSINGLE LIMIT $ m
<br />Ew moipem 1 000,000 ✓
<br />){ ANYAUTO
<br />BODILY INILRY(Perpersem( S �xixixxxx
<br />ALL D'A'N ED { 4CHEDULEO
<br />X AU7b6 I, _ AL1T'C.3::
<br />BODILY INJURY {Per SCCIU9,lfj, $
<br />x.r}%„�.'ixxx
<br />NON OWNED
<br />x HIRED AUTOS y' AUTOS
<br />nf20PCYETF'�At1AVE
<br />„(Earneoeon+,} $ tixx.Sx'xxx
<br />-XXXXXXX
<br />UMBRELLA LIAO
<br />OCCUR
<br />jNOTAPPLICABLE
<br />EACH OCCURRENCE $ x,](){xxxx
<br />_.
<br />AG'0456ATE
<br />EXCESS LIAR
<br />CLAIMS -MADE
<br />UEO RETENTIOW,,$,,,,,,,,,,w „
<br />$ }.;x'/,'J{xxx
<br />H
<br />WORKERS COMPENSATION
<br />IN WC 4641353 lAL).i
<br />CR
<br />rF
<br />A
<br />AND EMPLCYERS'LYACYLITY
<br />1111 /ZU➢5 11/1/20766
<br />INC NC 464{354 � ) 11(12015 I1111T0t6
<br />.., PTA7L1 -E-._ .. _..
<br />A
<br />OFf1i.EtbTdEMaER CXCLUD @A9 � NIA
<br />,WY
<br />VvC 0139244 {{ 7111 `2C I5 lljl /2016
<br />�EL..AGH ACCIDENT S]000000 v
<br />_. -._ _�� _
<br />{M&aAaSCrry Fn Nfi}
<br />EA EMPLOYFF�4.)aQ{}{J
<br />yyo3
<br />DESCERIMUMi OF CPERATaaNEeeinwE
<br />_.
<br />EI,. DISEASE POLICY LIMIT S (}(}Q 000
<br />mELDISEASE
<br />DESCRIPT(ON OP OPERATIONS l LOCATIONS I VEHICLES {ACORO 101, Addid ual Remark, SChmdi-0a, may be atlach d lr more apace Le required)
<br />PM 175203, Sanitary Sewer and Water Financial PIn REP. The City, its comers, gnueleyaes, agents, Volunteers and reprCeentuTives we iat'luded AS add:f3Unal
<br />insured on €iieneral Liability as required by Tvrisen Contras.
<br />118632108
<br />City Of Santa Ana SHOULD ANY OF THE ABOVE DESCRIBED' POLICIES BE CANCELLED BEFORE
<br />220 S. Daisy Avenue, M 85 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />Santa Ana C.A. 92703 ACCORDANCE WITH THE POLICY PROVISIONS,
<br />AUTHORIZED R @PRESENTATIVE'(
<br />ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
<br />
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