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T DATE [MMI]D?YYYYI
<br />,�►aCtC7► [7 "" CERTIFICATE OF LIABILITY INSURANCE
<br />0911212016
<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 IINSURER(S), AUTHORIZED
<br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
<br />IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the poticy(ies) must he 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 Phone. (925)930.9464 Fax (925)930 -9949 CONTACT
<br />NAME Stout Insurance Brokers, Inc.
<br />STOUT INSURANCE BROKERS, INC. PHONE 925 930 -9464 (F�t N.) 925 930- 9949
<br />P,O. BOX 400 F-MAI U, Est} ( ) _ ( ) _
<br />EMAIL certsa@stoutinsurance.com
<br />ROSEVILLE CA 95661 ADDRESS: __. .
<br />UVy CKlit9 =.'t, t.CK I uriUAV i C IVUIYIRCK: 4LlQU Kr VIWUN NU[Wbt: C:
<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 ALLTHE TERMS,
<br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
<br />INSR A,UD L SUER POLICY EFF POLICY EXP
<br />LTR -... TYPE OF INSURANCE ..INSR VVVO POLICY NUMBER .._ (MMIDDIYYYYI._ (MMIDDlYYYYI ... ..... _.LIMITS
<br />A GENERAL LIABILITY VBA456084 07107116 07107117 EACH OCCURRENCE S 1,000,000
<br />DAMAGE TO RENTED
<br />X '.:COMMERCIAL GENERAL. LIABILITY PREMISES (Eaoccaarence) '$ 100,000
<br />CLAIMS-MADE X OCCUR I MED EXP (Any one person) 5,000
<br />.,._ _... ....... I PERSONAL & ADV INJURY S... 11,0.:00,000
<br />GENERAL AGGREGATE: $ .2,000,000
<br />GEN'L AGGREGATE LIMIT APPLIES PER. PRODUCTS COMPIOPAGG $ 2,000,000
<br />X POLICY PRO-
<br />JECT ' LOC EMPLOYEE BENEFITS 1_11 $ 11000,000
<br />B AUTOMOBILE LIABILITY 02290192.3 07107116 071071117 {" comm D SINGLE LYhdkT
<br />I.(F',a aecidanl} $ ......... .1,00'0,000
<br />ANY AUTO 1
<br />ALL.OIAI14ED S(°HFn1Ji'ED
<br />:AUTOS ° AUTOS
<br />X HIRED AUTOS X NON -OWNED
<br />AUTOS
<br />C UMBRELLA. LIAR OCCUR _.....
<br />''.... EXCESS LIAR CLAIMS -MADE
<br />_.DEC RETENTION$
<br />D WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY
<br />ANY PROPRIETORIPARTNER /EXECUTIVE Y f M
<br />OFFICEWMEMBER. EXCLUDED? NIA
<br />(Mandatory In NH)
<br />It yes, d cr be un7der
<br />I.,. DESCRIPTION OF OPERATIONS below
<br />INSURER(S) AFFORDING COVERAGE
<br />NAIL #
<br />w3URFRA Covington Specialty) Insurance Company
<br />13027
<br />Agency Lic#: OD85866
<br />INSURED
<br />MODULAR BUILDING CONCEPTS, INC..
<br />INSURER B Progressive Insurance
<br />11770....._..
<br />INSURER : National Union Fire Insurance Company
<br />19445
<br />12580 STOTLER CT. .
<br />POWAY CA 92064 2 c"
<br />INSURERD. State Compensation Insurance Fund
<br />35076
<br />INSURER E
<br />.._._ _.. ..._..
<br />INSURER F
<br />$
<br />UVy CKlit9 =.'t, t.CK I uriUAV i C IVUIYIRCK: 4LlQU Kr VIWUN NU[Wbt: C:
<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 ALLTHE TERMS,
<br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
<br />INSR A,UD L SUER POLICY EFF POLICY EXP
<br />LTR -... TYPE OF INSURANCE ..INSR VVVO POLICY NUMBER .._ (MMIDDIYYYYI._ (MMIDDlYYYYI ... ..... _.LIMITS
<br />A GENERAL LIABILITY VBA456084 07107116 07107117 EACH OCCURRENCE S 1,000,000
<br />DAMAGE TO RENTED
<br />X '.:COMMERCIAL GENERAL. LIABILITY PREMISES (Eaoccaarence) '$ 100,000
<br />CLAIMS-MADE X OCCUR I MED EXP (Any one person) 5,000
<br />.,._ _... ....... I PERSONAL & ADV INJURY S... 11,0.:00,000
<br />GENERAL AGGREGATE: $ .2,000,000
<br />GEN'L AGGREGATE LIMIT APPLIES PER. PRODUCTS COMPIOPAGG $ 2,000,000
<br />X POLICY PRO-
<br />JECT ' LOC EMPLOYEE BENEFITS 1_11 $ 11000,000
<br />B AUTOMOBILE LIABILITY 02290192.3 07107116 071071117 {" comm D SINGLE LYhdkT
<br />I.(F',a aecidanl} $ ......... .1,00'0,000
<br />ANY AUTO 1
<br />ALL.OIAI14ED S(°HFn1Ji'ED
<br />:AUTOS ° AUTOS
<br />X HIRED AUTOS X NON -OWNED
<br />AUTOS
<br />C UMBRELLA. LIAR OCCUR _.....
<br />''.... EXCESS LIAR CLAIMS -MADE
<br />_.DEC RETENTION$
<br />D WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY
<br />ANY PROPRIETORIPARTNER /EXECUTIVE Y f M
<br />OFFICEWMEMBER. EXCLUDED? NIA
<br />(Mandatory In NH)
<br />It yes, d cr be un7der
<br />I.,. DESCRIPTION OF OPERATIONS below
<br />DESCRIPTION OF OPERATIONS/ LOCATIONS / VEHICLES (Attach ACORD 101, Additto...... .. l
<br />THE CITY OF SANTA ANA, ITS OFFICERS, EMPLOYEES, AGENTS AND
<br />THE ATTACHED ENDORSEMENT.
<br />bV
<br />� ti ,�w\
<br />pace is (required)
<br />TIVES SHALL BE NAMED AS ADDITIONALLY INSURED AS PER
<br />GERERAL LIABILITY SHALL BE PRIMARY AND NON CONTRIBUTORY AS PER THE ATTACHED ENDORSEMENT.
<br />** THE CITY WILL BE MAILED 30 DAYS WRITTEN NOTICE OF POLICY CANCELLATION
<br />CERTIFICATE HOLDER CANCELLATION
<br />CITY OF SANTA ANA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />20 CIVIC CENTER PLAZA THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />SANTA ANA, CA 92702 ACCORDANCE WITH THE POLICY PROVISIONS.
<br />AUTHORIZED REPRESENTATIVE
<br />Attention:
<br />Stephen T. Stout
<br />ACORD 25 (2010105) (0 1988 -2010 ACORD CORPORATION. All rights reserved.
<br />The ACORD name and logo are registered marks of ACORD
<br />BODILY INJURY (Per person)
<br />S
<br />BODILY INJURY (Per amidenf:) .
<br />5
<br />PROPERTY DAMAGE
<br />� —... ......... _......
<br />(pea mddentJ...
<br />.._._ _.. ..._..
<br />$
<br />017200794 _
<br />07107116
<br />07107117 EACH OCCURRENCE
<br />$ 1 „000,000
<br />AGGREGATE.
<br />$ 1,000,,000
<br />S
<br />_.... ._....
<br />9141539 -16
<br />0..
<br />0910711
<br />09107 %17 X T-ODYL TU OTM
<br />TURr LIrdlTS ER
<br />5
<br />E L EACH ACaDENT
<br />S 1,000,000
<br />N
<br />El. DISEASE -EA EMPLOYEE
<br />$ 1,000,000
<br />E L DISEASE - POLICY LIMIT
<br />$ 1,000,000
<br />DESCRIPTION OF OPERATIONS/ LOCATIONS / VEHICLES (Attach ACORD 101, Additto...... .. l
<br />THE CITY OF SANTA ANA, ITS OFFICERS, EMPLOYEES, AGENTS AND
<br />THE ATTACHED ENDORSEMENT.
<br />bV
<br />� ti ,�w\
<br />pace is (required)
<br />TIVES SHALL BE NAMED AS ADDITIONALLY INSURED AS PER
<br />GERERAL LIABILITY SHALL BE PRIMARY AND NON CONTRIBUTORY AS PER THE ATTACHED ENDORSEMENT.
<br />** THE CITY WILL BE MAILED 30 DAYS WRITTEN NOTICE OF POLICY CANCELLATION
<br />CERTIFICATE HOLDER CANCELLATION
<br />CITY OF SANTA ANA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />20 CIVIC CENTER PLAZA THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />SANTA ANA, CA 92702 ACCORDANCE WITH THE POLICY PROVISIONS.
<br />AUTHORIZED REPRESENTATIVE
<br />Attention:
<br />Stephen T. Stout
<br />ACORD 25 (2010105) (0 1988 -2010 ACORD CORPORATION. All rights reserved.
<br />The ACORD name and logo are registered marks of ACORD
<br />
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