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--—Ir
<br />DATE (MMIDDIYYYY)
<br />" CERTIFICATE OF LIABILITY INSURANCE
<br />1113012016
<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 CONTRACTBETWEEN 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
<br />CONTACT
<br />_. _
<br />MARSH USA, INC.
<br />-,..
<br />PHIONE FAX
<br />Atc Np1.;....
<br />99 HIGH STREET
<br />-tAtc, No Ext . _,
<br />BOSTON, MA 02110
<br />E-MAIL
<br />Ato: Boston:nrtreqLJest@Marshi.com Fax: 212-948-4377
<br />AFFORDING COVERAGE NAIL p
<br />INSURERS ._._
<br />116924947-all-GA'WU-16-17
<br />INSURER A: Federal nsurance Company 20281
<br />INSURED
<br />INSURER 9: Great Northern Insurance Company .26303
<br />Kapsch TraffcCom Transportation NA, Inc
<br />INSURER C: Chubb Indemnity Insurance Company 12777
<br />8201 Greensboro Drive
<br />Suite 1002
<br />INSURER D: _ ....._,_
<br />McLean, VA 22102
<br />.
<br />...
<br />INSURER 6.: ...... .......... .-...._. ............ ......... ..
<br />�.
<br />INSURER. P :
<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 />_.._ -_
<br />IINSfi AQDL SUBR, ........ ...... ...... POLICY EFF..... POLICY EXP LIMITS
<br />LTR TYPE OF INSURANCE man WVD POLICY NUMBER MMIDDIYYYY MMIDDtYYYY
<br />.,9949-16-74
<br />A
<br />X COMMERCIAL GENERAL LIABILITY
<br />1.1136!2316
<br />11 13012017
<br />EACH OCCURRENCE.. $1,000,000 ...
<br />... _.._ -
<br />, CLAIMS -MADE � OCCUR
<br />DAMJsGE TO RENTED—$ 1,000,000
<br />PREMISES IEa occurrence)-........--
<br />MED EXP (Any one person) $ 10,000
<br />PERSONAL & ADV INJURY '... $ 1,000„000
<br />GEN'L AGGREGATE LIMIT APPLIES PER:
<br />GENERAL AGGREGATE $.............. 2.,000,000
<br />X JEGT
<br />POLICY PRO- LOC
<br />PRODUCTS - GOMPIOP AGG S 2,000,000
<br />$
<br />OTHER,
<br />1113012016
<br />11130/2017
<br />COMBINEDSINGLE LIMIT S 1,000,000,
<br />B
<br />AUTOMOBILE LIABILITY
<br />..7356-51-01...
<br />Ea aBINED
<br />-. ....... . _....-._._
<br />BODILY INJURY (Per person) S
<br />ANY AUTO
<br />ALL OWNED SCHEDULED
<br />BODILY INJURY (Per accident) 5
<br />.._.,.. AUTOS AUTOS
<br />X NON -OWNED
<br />I
<br />_,,,....... ..._,.........
<br />PROPERTY DAMAGE $
<br />XI
<br />X HIRED AUTOS
<br />(Per acGdenl ......
<br />... .. .-
<br />A
<br />X UMBRELLA LIAR X OCCUR
<br />798364-37
<br />1113612016
<br />1113012017
<br />EACH OCCURRENCE $ 5,000,000
<br />..
<br />.... EXCESS LIAR CLAIMS -MADE...,
<br />AGGREGATE. .,., . $ 5,000,000
<br />C
<br />DED RETENTION $
<br />WORKERS COMPENSATION
<br />(17)7175-13-2$
<br />1113012016
<br />1113012017
<br />$
<br />X STATUTE ORIS
<br />.._....__ .
<br />AND EMPLOYERS' LIABILITY YIN
<br />E L,, EACH ACCIDENT S 61),660
<br />ANY PROPRIETOMPARTNERIFXECUTIVE �p�y��
<br />N
<br />NIIA
<br />1 n(1....
<br />.. ..... .......... .....,
<br />OFFiCERIVEMBER EXCLUDED?
<br />L DISEASE - EA EMPLOYF $ 00 606
<br />(Mandatory in. NH)
<br />E
<br />It yes, describe under
<br />E.L. DISEASE -POLICY LIMIT S 1,000,006
<br />DESCRIPTION OF OPERATIONS be[ow
<br />DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES (ACORD 101,. Additional Remarks Schedule, may be attached If more space is required)
<br />City of Santa Ana„ PWA - Transportation & Traffic Engineering Department are are included as additional insured (except for Workers Compensaflon) where required by written contract. Waiver of Subroga ion is
<br />applicable in favor of City of Santa Ana, PWA - Transportation & Traffic Engineering Department on the General Liability, Auto Liability. !Umbrella Liability, and Workers Compensation where required by written
<br />contract.
<br />O:I=K I IHIUA I. t IHVLUtK
<br />City of Santa Ana SHOULD ANY OF THE, ABOVE, DESCRIBED POLICIES BE CANCELLED BEFORE
<br />Atln: Vinh Nguyen, P.E., Sr. Civil Engineer THE EXPIRATION DATE THEREOF', NOTICE WILL BE DELIVERED IN
<br />PWA - Transportation & Traffic Engineering ACCORDANCE WITH THE POLICY PROVISIONS,
<br />20 Civic Center Plaza
<br />Santa Ana, CA 92701 AUTHORIZED REPRESENTATIVE
<br />of Marsh USA Inc.
<br />Elizabeth Stapleton -
<br />IJIUU?J-tU-ll+iAt,UMLJUur%r'vr%^IlvlM. r+ur ar+,I.,ea ucaaxYeu.
<br />ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
<br />a
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