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ACORH CERTIFICATE OF LIABILITY INSURANCE
<br />`�
<br />DATE(MMOO/YYYY)
<br />12/13/2016
<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(les) 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 (leu of such endorsements .
<br />PRODUCER
<br />Arthur J. Gallagher& Co.
<br />Insurance Brokers of CA, Inc. LIC #0726293
<br />1255 Battery Street, Suite 450ADDRESEL
<br />CONTACT
<br />NAME:
<br />P"°NE .415-536-8617 FAx .415-536-8627
<br />E-MAIL
<br />INSURERS AFFORDING COVERAGE
<br />NAIC k
<br />San Francisco CA 94111
<br />INSURERA:American Fire and Casualty Company
<br />24066
<br />12/4/2016
<br />INSURED CSGCONS-01
<br />INSURERB:Ohio Casualty Insurance Company
<br />24074
<br />CSG Consultants, Inc.
<br />INSURERC:Cypress Insurance Company CA
<br />10855
<br />550 Pilgrim Drive
<br />Foster City, CA 94404
<br />INsuRERo:Arch Insurance Company
<br />11150
<br />DAMAGE(RENTED
<br />PREMISESSEa occurrence)
<br />INSURER E
<br />NN"aF:
<br />$5,000
<br />COVERAGES CERTIFICATE NUMBER- 1349564287 RFVISI11N NIIMRFR-
<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 />ILm
<br />TYPE OF INSURANCE
<br />(NSD
<br />WVD
<br />POLICYNUMBER
<br />POLICY EFF
<br />MMIDDIYYYY
<br />POLICY EXP
<br />MWDDM'VY
<br />LIMITS
<br />B
<br />,X
<br />COMMERCIAL GENERAL LIABILITY
<br />Y
<br />BKO1757695795
<br />12/4/2016
<br />12/4/2017
<br />EACH OCCURRENCE
<br />$1,000,000
<br />CLAIMS -MADE ❑X OCCUR
<br />DAMAGE(RENTED
<br />PREMISESSEa occurrence)
<br />$500,000
<br />MED EXP (Any one person)
<br />$5,000
<br />PERSONAL &ADV INJURY
<br />$1,000,000
<br />AGGREGATE LIMIT APPLIES PER:
<br />POLICY [�] PRO- [X—] LOC
<br />JECT
<br />GENERAL AGGREGATE
<br />$2,000,000
<br />GEN'L
<br />PRODUCTS -CONI AGO
<br />$2,000,000
<br />$
<br />OTHER:
<br />A
<br />AUTOMOBILE
<br />LIABILITY
<br />Y
<br />BAA1757695795
<br />12/4/2016
<br />12/4/2017MBINED
<br />INGLE
<br />Ea accident
<br />$ 1,0°0,°00
<br />BODILY INJURY (Per person)
<br />$
<br />X
<br />ANY AUTO
<br />OWNED SCHEDULED
<br />AUTOS ONLY AUTOS
<br />BODILY INJURY Per accident
<br />( )
<br />$
<br />AUTOS ONLY AUTOS ONLY
<br />PROPERTY DAMAGE
<br />Per accident
<br />$
<br />A
<br />X
<br />UMBRELLA LIAR
<br />X
<br />OCCUR
<br />USA1757695795
<br />12/4/2016
<br />12/4/2017
<br />EACH OCCURRENCE
<br />$5,000,000
<br />AGGREGATE
<br />$5,000,000
<br />EXCESS LIAR
<br />CLAIMS MADE
<br />DED RETENTION$
<br />$
<br />C
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY YIN
<br />CSWC715232
<br />12/4/2016
<br />12/4/2017
<br />y, PER Om -
<br />STATUTE ER
<br />E1. EACH ACCIDENT
<br />$1,000,000
<br />ANY PROPRIETOR/PARTNER/EXECUTIVE N
<br />OFFICER/MEMBER EXCLUDED9
<br />NIA
<br />EL DISEASE - EA EMPLOYEE
<br />$1,000,000
<br />(Mandatory in NH)
<br />If yes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />EL DISEASE -POLICY LIMIT
<br />$1,000,000
<br />D
<br />Professional Liability7
<br />08801
<br />12/4/2016
<br />12/4/2017
<br />Each Claim $5,000,000
<br />retrodate: 1/1/1991
<br />7
<br />Aggregate $5,000,000
<br />Deductible'. $50,000
<br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required)
<br />re: consultant agreement for municipal plan check services made and entered 11/15/16. City of Santa
<br />Ana, a charter city and municipal corporation organized and existing under the Constitution and laws of
<br />the State of California, its officers, employees, agents, volunteers and representatives are included as
<br />additional insureds on a Primary & Non -Contributory basis on GL & Auto with 30 Day Notice of
<br />Cancellation per attached. 30 Day Notice of Cancellation on Professional per attached. 30 Day Notice of
<br />Cancellation on WC is not available.
<br />CERTIFICATE HOLDER / $ % CANCELLATION "
<br />©1988-2015 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2016/03) 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, Clerk of the City Council
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />20 Civic Center Plaza (M-30)
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />PO Box 1988
<br />Santa Ana CA 92702-1988
<br />AAU+{THHORRIZ�E,D REPRESENTATIVE
<br />USA
<br />©1988-2015 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
<br />
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