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HOUS&HA-01 SMARTIN <br />Ill- ° CERTIFICATE OF LIABILITY INSURANCE <br />`••---"'' <br />DATE (M/201YYY) <br />6/27/2017 <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 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 License # OC36861 <br />Inland Empire-Alliant Insurance Services, Inc. <br />735 Carnegie Dr Ste 200 <br />San Bernardino, CA 92408 <br />CONTACT <br />NAME: Stacy Guillen <br />PHONE 909 886-9861 FAX 909 886-2013 <br />A/c No Ext): ( ) (A/C, No): ( ) <br />-MAILADDRESS: SGuillen@alliant.com <br />E-MAIL—ADDRESS: <br />INSURER(S) AFFORDING COVERAGE <br />NAIC # <br />INSURERA:Ironshore Specialty Insurance Co <br />25445 <br />INSURED <br />INSURER B: Nationwide Mutual Insurance Company <br />23787 <br />Houston & Harris P C S Inc <br />INSURERC: RSUI Indemnity Company <br />22314 <br />INSURER D: Cypress Insurance Company (CA) <br />10855 <br />21831 Barton Road <br />Grand Terrace, CA 92313 <br />INSURER E: Landmark American Insurance Company <br />33138 <br />INSURER F: <br />MED EXP (Any one person) <br />COVERAGES CERTIFICATE NUMBER: 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. <br />INSR <br />LTR <br />TYPE OF INSURANCE <br />ADDL <br />INSD <br />SUBR <br />WVD <br />POLICY NUMBER <br />POLICY EFF <br />MM/DD/YYYY <br />POLICY EXP <br />MM/DD/YYYY <br />LIMITS <br />A <br />X <br />COMMERCIAL GENERAL LIABILITY <br />EACH OCCURRENCE <br />$ 1,000,000 <br />CLAIMS -MADE 1XII OCCUR <br />X <br />AGS0027605 <br />06/24/2017 <br />06/24/2018 <br />DAMAGE TO RENTED <br />PREMISES Ea occurrence <br />50 000 <br />$ , <br />MED EXP (Any one person) <br />$ 5,000 <br />PERSONAL &ADV INJURY <br />$ 1,000,000 <br />AGGREGATE LIMIT APPLIES PER: <br />GENERAL AGGREGATE <br />$ 2,000,000 <br />GEN'L <br />POLICY PRO- <br />JECT [::] LOC <br />PRODUCTS - COMP/OPAGG <br />$ 2,000,000 <br />$ <br />OTHER: <br />AUTOMOBILE LIABILITY <br />COMBINED SINGLE LIMIT <br />Ea accident), <br />$ 1000000 <br />, <br />BODILY INJURY (Per person) <br />$ <br />B <br />X ANY AUTO <br />ACP3036645740 <br />06/24/2017 <br />06/24/2018 <br />ALL OWNED SCHEDULED <br />AUTOS AUTOS <br />BODILY INJURY (Per accident) <br />$ <br />XX NON -OWNED <br />HIRED AUTOS AUTOS <br />PROPERTY DAMAGE <br />Per accident <br />$ <br />UMBRELLA LIAB <br />X <br />OCCUR <br />EACH OCCURRENCE <br />$ 4,000,000 <br />C <br />X <br />EXCESS LAB <br />CLAIMS -MADE <br />NHA242820 <br />06/24/2017 <br />06/24/2018 <br />AGGREGATE <br />$ 4,000,000 <br />DED X RETENTION $ 0 <br />$ <br />D <br />WORKERS COMPENSATION <br />AND EMPLOYERS' LIABILITY Y/N <br />ANY PROPRIETOR/PARTNER/EXECUTIVE <br />X <br />HOWC705376 <br />09/01/2016 <br />09/01/2017 <br />X PER OTH- <br />STATUTE ER <br />E.L. EACH ACCIDENT <br />$ 1,000,000 <br />OFFICER/MEMBER EXCLUDED? ❑ <br />(Mandatory in NH) <br />N/A <br />E.L. DISEASE- EA EMPLOYEE <br />$ 1,000,000 <br />If yes, describe under <br />DESCRIPTION OF OPERATIONS below <br />E.L. DISEASE- POLICY LIMIT <br />$ 1,000,000 <br />E <br />Professional Liabili <br />LHR832189 <br />06/24/2017 <br />06/24/2018 <br />Agg/Each Claim Limit 2,000,000 <br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) <br />Job: Operations pertaining to named insured for Certificate Holder. <br />City of Santa Ana is Additional Insured as respects to General Liability per endorsement attached. Waiver of Subrogation applies as respects to worker's <br />compensation per endorsement attached. A-2014-174_02 <br />7/27/17, page 1 of 4 <br />K <br />CERTIFICATE HOLDER CANCELLATION <br />ACORD 25 (2014/01) <br />© 1988-2014 ACORD CORPORATION. All rights reserved. <br />The ACORD name and logo are registered marks of ACORD <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />City of Santa Ana <br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />Purchasing Division <br />20 Civic Center Plaza M-16 <br />AUTHORIZED REPRESENTATIVE <br />f <br />�4� <br />Santa Ana, CA 92701 <br />1 <br />ACORD 25 (2014/01) <br />© 1988-2014 ACORD CORPORATION. All rights reserved. <br />The ACORD name and logo are registered marks of ACORD <br />