|
CERTIFICATE OF LIABILITY INSURANCE DATE 5/26/2 a16A,DDl
<br />-------•-I2 6
<br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIOHTS 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 TIME nSUING INSURER(S), AUTHORIZED
<br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
<br />IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) rnust be endorsed. If SUBROGATION 15 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 N FACT Sherri Tien-Plvxt
<br />The Liberty company Insurance Brokers PHONE . (818} 914-3960 F,ut (a56SB3S-69B3
<br />CA License #DI�79653 E-MAIL A1C Na:
<br />RES , sharriO libartycompany , com
<br />21820 Burbank Blvd Suite 330
<br />INSURERS AFFORDING COVERAGE NAIC 6
<br />Woodland Hills CA 91367 INsuRERA:Trav®lore Pro ®rt Casualt Co of 25674
<br />INSURED
<br />1NSURERB:The Travelers Ind Cc of CT 25682
<br />General Pump Company, Inc. � WSURER c :I�isuti1119 ins Company 17370
<br />159 North Acacia Street
<br />San Dimas CA 91773
<br />UVlZKAUtr,'S CERTIFICATE NUMBER:16/17 GL/Auto/1WC/ _
<br />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 />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJEINDICATED. NOTWITHSTAN13ING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
<br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CT TO ALL THE TERMS,
<br />AD
<br />TYPE OF INSURANCE PO 1 Y EFF
<br />Nstz.uYVD POLICY Nt1M9Ek ruu,� ,,,.,,,.,
<br />ALGENERAL LIABILITY
<br />EACH OCCURRENCE
<br />$ 1,000,00C /
<br />A
<br />CLAIMS -MADE OCCUR
<br />PRE ISE5 Ea occurrence
<br />$ 300,00(
<br />X.
<br />Blanket Addl Insured X 5306929N819TIr,16
<br />6/1/2016
<br />6/1/2C17 MEDEXF(Agone peraon}
<br />.....-_
<br />$ - 5,BOO
<br />- '--- -
<br />PERSONAL. & ADV INJURY
<br />3 1,000,00C
<br />AGGREGATE LIMIT APPLIES PER
<br />--PERSONAL - ----'-.--
<br />X,
<br />GENERAL. AGGREGArE
<br />S 2 , 000 00 C
<br />P01JCY JECT LGG
<br />- -
<br />PRODUCTS COMPIOPAGG
<br />S 2,000,00C
<br />OTHER:
<br />EMPeyee Benefrts
<br />$ 2, 000 00C
<br />AUTOMOBILE
<br />LIABILITY
<br />COMBINED S1 GL IM!
<br />,
<br />� - �
<br />ANY AUTO ALLOWNEO - SCHEDULED
<br />Fa ac�IdentL -
<br />BODILY INJURY (Par pen;onF
<br />5 1, 000 , 00C�
<br />$ _ --- - -
<br />_ ._..,
<br />AUTOS _._._. AUTOS 106929N819T:L16
<br />6/1/2616
<br />6/1/2017 BODILY AJURY,Peraccdsnll
<br />$
<br />HIRED AUTOS NON -OWNED , AUTOS
<br />PROPERTY DAMAGE-
<br />X
<br />UMBRELLA LAB X
<br />Uninsured motorist combined
<br />$ 2,000, 00 C
<br />-- i OCCUR
<br />E1fCE98 LIAR
<br />EACH OCCURRENCE
<br />-_ --
<br />... 4,00.0.'.000
<br />A ,.....
<br />CLAIMS -MADE
<br />-- --1 - -----
<br />AGGREGATE
<br />IS 4,000,00C
<br />DIED RETt NTION 0 Ci3r�6929NB19TLL16
<br />6/1/2016
<br />6/1/2017
<br />.
<br />,
<br />AND EMPLOYERS' LIABILITY YIN
<br />X PER 0 H-
<br />STATUTE-
<br />ANY PRflPRIETOWPARTNEFU�(ECUTIVE '-
<br />-.
<br />OFFICENMEMBER EXCLUDE]? y NIA
<br />A
<br />F.L.EACH ACCIDENT $
<br />1 000 DOC
<br />:(Mandatory In NHI - 17E5946N799TSL16
<br />K yyes, dsscnba under
<br />6/1/2016 6/l/2017 E. L. DISEASE EA EMPLOYEE $
<br />- __.. -_ .
<br />x ,
<br />1 000 , OOC
<br />,0
<br />OESCRIPTION OF OPERATIONS tratow
<br />F.L. bISEASE-Ppl_fCY LIMIT $
<br />1 D00 OOC
<br />C Contractors Pollution CPL201715310
<br />2/5/2C16 2/5/2017 General Aggregate Limit
<br />$2,00O,000
<br />Liability
<br />Each Pollution Condition
<br />$1,000,00C
<br />•--• .+,..� , ' a A wno i Vpnwies (AL7ORO 101, Additional Remarks Schedule, may be attached If more space Is requlred)
<br />Where required by written contract, the City of Santa Ana, its officers, employees, agents, volunteers
<br />and representatives are included as Additional Insured with regard to liability and defense of quits
<br />arising from the operations and uses performed by or on behalf of the Named Insured per the attached CG
<br />D2 46 08 05.
<br />TE
<br />City of Santa Ana
<br />20 Civic Centex Plaza - Ross
<br />Annex {M- )
<br />Santa Ana, CA 92701.
<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 />AW trrvrci[t:r] REPRESENTATIY@
<br />Sherri Ben-:dun/RSPNI-
<br />01988-2014 ACOiRD CORPORATION. All rights reserved
<br />ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
<br />1N50251�Pr nm
<br />
|