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. o" ® CERTIFICATE CF LIABILITY INSURANCE
<br />DATE bfY7
<br />�......-�"
<br />1.
<br />9114/
<br />09114/2017
<br />0 9/1 412 01 7
<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 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 />PRODUCER
<br />CONTACT
<br />NAME;
<br />AHCNNo Ext): 888 780-5381 FAX No]: 877 737-8498
<br />WILLIS OF ILLINOIS, INC,
<br />E-MAIL
<br />Certificate@hanover.cam
<br />233 B WACKER DR.,SUITi.= 2000
<br />MED EXP oneperson) $ 10,000
<br />INSURERS AFFORDING COVERAGE NAIC#
<br />CHICAGO, IL 60606
<br />INSURER A: Citizens Ins Ca of America 31534
<br />INSURED
<br />INSURER B: Hanover American Ins Co 36064
<br />INSURER C:
<br />BUCKNAM INFRASTRUCTURE GROUP INC
<br />INSURER DINSURER
<br />3548 SEAGATE WAY SUITE 230
<br />OBC A399956 03
<br />09/16/2017
<br />E:
<br />OCEANSIDE CA 92056
<br />PERSONAL B ADV INJURY $ 1,000,000
<br />GEN'L AGGREGATE UMIT APPLIES PER:
<br />POLICY jEC7 LOC
<br />INSURER F:
<br />9.:UVtKAWt5 CEK7IFICAIE NUM13ER: RFVISION NIIMRi
<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 />ILTR
<br />TYPE OF INSURANCE
<br />AD
<br />POLICY NUMBER
<br />POLICY
<br />LIC
<br />LIMITS
<br />X COMMERCIALGENERAL LIABILITY
<br />CLAIMS -MADE � OCCUR
<br />EACHOCCURRENCE $ 1,000,000
<br />DAMAGE TO RENTESES (Es D $ 1,000,000
<br />MED EXP oneperson) $ 10,000
<br />A
<br />Y
<br />Y
<br />OBC A399956 03
<br />09/16/2017
<br />09/15/2018
<br />PERSONAL B ADV INJURY $ 1,000,000
<br />GEN'L AGGREGATE UMIT APPLIES PER:
<br />POLICY jEC7 LOC
<br />GENERAL AGGREGATE $ 2,000,000
<br />PRODUCTS - COMP/OP AGG $ 2,000,000
<br />$
<br />OTHER:
<br />AUTOMOBILE
<br />LIABILITY
<br />COMBI EDSINGLELIMI $ 1,000,000
<br />Ea accident
<br />ANY AUTO
<br />BODILY INJURY (Per person) $
<br />AOWNED
<br />IX
<br />SCHEDULED
<br />AUTOSONLY AUTOS
<br />HIRED X NON -OWNED
<br />AUTOS ONLY AUTOS ONLY
<br />Y
<br />Y
<br />OBC A399956 03
<br />09/16/2017
<br />09/16/2018
<br />BODILY INJURY (Per accident) $
<br />PROPERTY DA MAGE $
<br />Pe
<br />$
<br />X
<br />UMBRELLALIAB
<br />IOCCUR
<br />EACH OCCURRENCE $ 9,000,000
<br />A
<br />EXCESSLIAB
<br />CLAIMS -MADE
<br />Y
<br />Y
<br />OBC A399956 03
<br />09/16/2017
<br />09/16/2018
<br />AGGREGATE $ 9,000,000
<br />DED I I RETENTION $
<br />$
<br />B
<br />WORKERS COMPENSATIONPER
<br />AND EMPLOYERS' LIABILITY YIN
<br />ANYPROPRIETORIPARTNER/EXECUTIVE
<br />OFFICER/MEMBEREXCWDED?
<br />(MantlatorylnNHJ
<br />, descrlbe under
<br />fins
<br />DCRIPTION OF OPERATIONS below
<br />NIA
<br />Y
<br />WZC A399946 03
<br />09/16/2017
<br />09/16/2018
<br />077-
<br />X S AA LITE ER
<br />EL EACH ACCIDENT $ 1,000,000
<br />-
<br />E.LDISEASE-EAEMPLOYEE $ 1,000,000
<br />E.L. DISEASE- POLICY LIMIT $ 1,000,000
<br />DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required)
<br />The City of Santa Ana, Its officers, employees, agents, volunteers and representatives are Additional Insured on the General Liability as their Interest may appear in regard to
<br />work performed or services provided by the Named Insured pursuant to the terms and conditions of form: 391-1937 (Additional Insured - Owners, Lessees or Contractors -
<br />Scheduled Person or Organization). Waiver of subrogation on General liability as provided by form: 391-1003. Waiver of subrogation on Workers Compensation as provided
<br />by: WC040306 (California Form). Excess/Umbrella to follow form.
<br />REVIEWED BY. EUNICE HEREDIA (PG 1 0 )
<br />THE CITY OF SANTA ANA
<br />20 CIVIC CENTER PLAZA M-36
<br />SANTA ANA CA 92701
<br />SHOULD ANY OFTHE ABOVE DESCRIBED POLICIES HE CANCELLED BEFORE
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />AUTHORIZED REPRESENTATIVE
<br />S" -L -L gk4uA
<br />®1988-2015 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2016!(}3) The ACORD name and logo are registered marks of ACORD
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