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A ?" CERTIFICATE OF LIABILITY INSURANCE DATE (MMdDD1YYYY)11 1 6/21 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(es) 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 dues not confer rights to the
<br />certificate holder in lieu of such endorsement(s).
<br />PRODUCER CONTACT Fernando Rivas
<br />NAME:
<br />ISU Insurance Services -- Centinel Agency, LLC PHO,NN ,Exti: (415)657-2000 FAX(AiCNo)! (415)657-2402
<br />(AIC250 Executive Park Blvd E-MAIL ADDRESS: fernando@isuca.com
<br />Suite 4800 INSURER(S)AFFORDING COVERAGE NAICtd
<br />San Francisco CA 94134 INSURER A:Scottsdale_insurance Company
<br />INSURED ., j� INSURER I9 Nationwide Mutual Ins Co
<br />California Barricade Dentals Inc INSURER C National Union Fire Ins Co of
<br />1550 E Saint Gertrude Place INSURER_D;State Compensation Ins. Fund
<br />INSURER E:
<br />Santa Ana CA 92705 INsuRERF:
<br />CnVFRAnP9 CFRTIFICGTFNIIMI1RF'R^16-17GL, WC. Auto. XS RFVI.RIONNIIMRFP°
<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 ADDL SUDR POLICY EFF POLICY (EXP
<br />LTR TYPE OF INSURANCE POLICY NUMBER MMIDDIYYYY MMIDD/YYYY (LIMITS
<br />X COMMERCIAL GENERAL LIABILITY
<br />EACH OCCURRENCE. $ 1,000,000
<br />A CLAIMS -MADE X .00CUR
<br />DAMAGE r0 RENTED 100 ,4740
<br />PF2EMl5ES (Fa occurrence) $
<br />X BCS0035435
<br />7/1/2016 7/1./201..7 MED EXP (Any one person) $ Excluded
<br />PERSONAL & ADV INJURY $ 1,000,000
<br />_.....
<br />GEN'L AGGREGATE LIMIT APPLIES PER.
<br />GENERAL AGGREGATE_.... $
<br />2,000,000
<br />X POLICY PRO-
<br />JECT _ LOC
<br />PRODUCrS- COMPIOPAGG $...._.. 2,000,000......
<br />OTHER:
<br />Employee Reneflrs $ 1,000,000
<br />AUTOMOBILE LIABILITY
<br />_-
<br />COMBINED SINGLE LIMIT $. 1,0Q0,000
<br />000, 000
<br />(Ea accident) ....... _.
<br />X... ANY AUTO
<br />BODILY INJURY (Per person) $
<br />B
<br />ATOS AUTOS X
<br />AUTOS AUTOACP 307745240
<br />_..
<br />7/1/2016 7/1/207.7 BODILY INJURY (Per accodentp $
<br />NON -OWNED
<br />X.
<br />PROPERTY DAMAGE
<br />$
<br />HIRED AUTOS ._. AUTOS
<br />(P�eraccudent]..
<br />$
<br />UMBRELLA LIAR X OCCUR
<br />EACH OCCURRENCE $.... 5,00.0,000
<br />C X.... EXCESS.LIAB CLAIMS MADE.
<br />_._
<br />AGGREGATE... . $ 5,,.000,000
<br />.. ... .......
<br />DEO RETENTIION$ EBU 01201369,6
<br />7/1/203.6 7/1/2017 $
<br />WORKERS COMPEN'>SATIONPER
<br />OTH-
<br />'X..
<br />AND EMPLOYERS' LIABILITY YXN
<br />STATUTE .EIS.
<br />ANY PROPRIETORiPARTNER/EXECUTIVE
<br />E L. EACH ACCIDENT $ 1,000,000
<br />OFFICERIMEMBER EXCLUDED? N 1 A_
<br />D (Mandatory in NH) 9063608-2016
<br />7/1/2016 7/1/2017 E DISEASE - EA EMPLOYEE $ 1,000,000
<br />If yes describe under
<br />DESCRIPTION OF OPERATIONS' below
<br />E.L DISEASE - POLICY LIMIT $ 1,000,000
<br />DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required'.)
<br />The City of Santa Ana, its officers, employees,
<br />agents, and representative are named a y'Iditional
<br />1
<br />insured per form. CG 20 33 04 13 and CG 20 37 04
<br />13 on the GL policy,
<br />Additional Insured applies per form AC 70 05 03
<br />16 on the Auto policy.
<br />Those to the insured'
<br />usual s operations.
<br />rl�e
<br />ptlb"w yS'
<br />CERTIFICATE HOLDER
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE.
<br />City of Santa Ana THE EXPIRATION DATE THEREOF, NOTICE WILL. BE DELIVERED IN
<br />20 Civic Center Plaza M-23 ACCORDANCE, WITH THE POLICY PROVISIONS.
<br />Santa Ana, CA 92702
<br />AUTHORIZED REPRESENTATIVE
<br />Josh Ferenc/FR �
<br />Ue 1988-2014 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
<br />INSG25 raral tint �
<br />
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