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.AC D CERTIFICATE OF LIABILITY INSURANCE RATE(MM1out(YYY}
<br />li* . 1112912017
<br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NA 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($), AUTHORIZED
<br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER,
<br />IMPORTANT; If the certificate holder Is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed.
<br />If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
<br />this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
<br />[C. ACT
<br />PRODUCER B111 Douglas Kourls Insurance Agency,inc r_ gL_
<br />10345 Danichrls Way PH.
<br />916.28f-564 F c Na,9I6-665.9577
<br />Elk Grove CA 95767
<br />INSURED Bender Rosenthal, Inc. INS R;aIolumia insurance company 21812
<br />4400 Auburn Boulevard, Suite 102
<br />Sacramento CA 95841 �entinel Insurance Company, Limited 11000 _
<br />%8gRenait3ran to State Insurance Company{.... 23stiE1 .+
<br />lasyg p c Mercer Insurance Company m.. 14470 w
<br />COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
<br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
<br />INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
<br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
<br />EXCLUSION8 AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE SEEN REDUCED BY PAID CLAIMS.
<br />.. _ ... ,_..w.... --
<br />IN$RT...•.,,.,.• ..__ _m.........., ....•..__. _..,..At1iiL11CNtt ,.._......... p ICYEFP..,..ISi.1�1-i'��(R..
<br />LT 1 TYPEAPiNBURANCE .Oki YN MtrER..
<br />_., _ ..,... _ .,..,.
<br />LIMITS
<br />C ✓ COMMERCIAL eEN9RALLIABILITY
<br />� OCCUR 57 SBA TX3133 0712112017 07/21/201a
<br />n�>s2,000,000
<br />�ERACH IOCCURRENCE
<br />0,00
<br />0aCLAIMS•MADE
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<br />.. ..� ...... ., _
<br />MEDEXPiAnyonepsnwn� ......:0,000,,...._
<br />_._........_._ ._
<br />PERSONALRAgV!NAJ 2,000,000 -»
<br />GCNLAGGR GATELgIMITAPPLIESPErZ
<br />0
<br />q#NRRALAGGREOATE $4,000,000
<br />✓ POLICYU JgC'T too
<br />PRgDt CTS CAMPlQPAGO $4,000,OOa
<br />.
<br />AUTOMOBILE LIABILITY ..
<br />✓
<br />✓
<br />- _ _.1204
<br />I 9
<br />$1,aoa,aoa
<br />ANYAUTO
<br />BODILY INJURY(Porporsnn)
<br />$
<br />B
<br />OWNED CHEDULED
<br />AUTOS ONLY C�O•S D
<br />✓ AUT0090MY N
<br />71APR36184B
<br />8t14/20i7
<br />08/1412p18
<br />BODILY INJURY (Par ncddent)
<br />�'�a��d ��AIrfA60
<br />- ....... ..............
<br />5
<br />$
<br />AUTOSO t�Y
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<br />UMBROLLAI.IAB ✓ OCCUR
<br />✓
<br />. ✓
<br />73R2
<br />7/1212017
<br />07/12/2018
<br />EACHbOcul}RENCE
<br />$3,000,000
<br />✓
<br />EXCESSLU1a CLAIMS MADE
<br />M.
<br />GL, AlltO and WC form
<br />AGeREOATE
<br />•., ...
<br />5,000r000
<br />DED R TENTIONS
<br />$-
<br />D
<br />WORKERS COMPENSATION
<br />C 9397974
<br />0610112017
<br />06/0112010
<br />✓ 8 PTLJ[E R
<br />AND EMPLQYERW UABILnY
<br />ANYPROPRIETOy PpARTNERIOXECUTIVE YIN
<br />OFPICERIMEM0gEREXCLU0E0? N
<br />NIA
<br />EL EACH ACCIDENT
<br />$1,aba,�00 • •
<br />{MandatarylnNN)
<br />EL DISEASE• EA;EMPLOYEP
<br />$110Otl,00D
<br />if yes, desaibo unstol000,000
<br />DESCRIPTION OF ERAT ON
<br />0,L, Dl$U ASE. POLI LIMIT
<br />.. '•"' µ ' ,.•.,
<br />$ 000,000
<br />A
<br />Professional LlabEliry
<br />®t
<br />r
<br />71 • 10662
<br />Deductible 15,000
<br />1/3012017
<br />11/3012018
<br />2,000,000 Per Occurrenc
<br />2,000,000Aggregate
<br />CLAIMS MADE
<br />Retro pate 11/30199
<br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHIOLEBACORD 101, Additional Romarlis Schedule, maybe attachad if more space Is required)
<br />30 Days Notice of Cancellation (10 Days for don•Payment of Premium)
<br />Jab: On -Call Right of Way property Appraisal Services
<br />BUSINESS LIABILITY AD ITIONAt, INSURED: City of Santa Ana, Its officers employees, agents, volunteers, and representatives and any
<br />other, person named In the written contract between the Named insured ana the Certificate Holder.
<br />Workers' Compensation Additional Insured, 30 Day Cancellation WC990017, and Waiver of Subrogation W
<br />40361.
<br />REVIEWED BY,
<br />EUNICE HEREDiA (PG • OF_
<br />City of Santa Ana
<br />20 Civic Center Plaza (M-30)
<br />PO Box 1988
<br />Santa Ana, CA 92702.1088
<br />Letica Lopez, 1Llopez5 oQsanta-ana.org
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />AUTHH�ORRIIZZEEDREPRESENTATI�VVE
<br />211
<br />ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
<br />Produced using Forma Ross Wob Software. wwwYormsaoss,00m (0) Improsshro Publishing 000.200.1977
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