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<br />,4o CERTIFICATE OF LIABILITY INSURANCE
<br />DATE(MM/DD,YYYY)
<br />08/17/2018
<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. If
<br />SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this
<br />certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
<br />PRODUCER
<br />Aon Risk services Central, Inc.
<br />Pittsburgh PA office
<br />CONTACT
<br />NAME:
<br />INC. No. Ext): (866) 283-7122 FAX
<br />No.): (800) 363-0105
<br />E-MAIL
<br />ADDRESS:
<br />EQT Plaza - Suite 2700
<br />625 Liberty Avenue
<br />INSURER(5) AFFORDING COVERAGE NAIC #
<br />Pittsburgh PA 15222-3110 USA
<br />INSURED
<br />INSURERA: XL Insurance America Inc 24554
<br />Michael Baker International, Inc
<br />5 Hutton Centre Drive
<br />suite 500
<br />INSURER B: Liberty Mutual Fire Ins Co 23035
<br />INSURER C: Liberty Insurance Corporation 42404
<br />Santa Ana CA 92707 USA
<br />INSURER D: Lloyd's Syndicate No. 2623 AA1128623
<br />INSURER E:
<br />EACH OCCURRENCE $2,000,000
<br />INSURER F:
<br />COVERAGES CERTIFICATE NUMBER: 570072717609 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. Limits shown are as requested
<br />I
<br />LTR
<br />TYPE OF INSURANCE
<br />INSD
<br />SUBK
<br />WVO
<br />POLICY NUMBER
<br />MM/DD/YYYY
<br />POLICY EXP
<br />MMIDDIYYYY
<br />LIMITS
<br />B
<br />X COMMERCIAL GENERAL LIABILITY
<br />TB
<br />EACH OCCURRENCE $2,000,000
<br />CLAIMS -MADE X❑ OCCUR
<br />General Liability
<br />$300,000
<br />PREMISES Ea occurrence
<br />MED EXP (Any one person) $10 , 000
<br />p
<br />PERSONAL &ADV INJURY $2,000,000
<br />to
<br />1-
<br />GENT AGGREGATE LIMITAPPLIES PER:
<br />GENERAL AGGREGATE $4,000,000
<br />JECT ❑LOC POLICY xPRO--X
<br />, ,r
<br />OTHER:
<br />O
<br />r
<br />BA52-681-004145-727
<br />AUTOMOBILE LU181Ln-Y
<br />08/30/2017
<br />08/30/2018
<br />COMBINED SINGLE LIMIT
<br />a accident) $2,000,000
<br />U)
<br />Commercial Auto - A05
<br />BODILY INJURY ( Per person)
<br />X ANY AUTO
<br />Z
<br />BODILY INJURY (Per accident)
<br />OWNED SCHEDULED
<br />w
<br />AUTOS ONLY AUTOS
<br />HIRED AUTOS NON -OWNED
<br />t0
<br />PROPERTY DAMAGE
<br />ONLY AUTOS ONLY
<br />Per accident)V
<br />w
<br />1:
<br />d
<br />A
<br />X
<br />UMBRELLALIAB
<br />X
<br />OCCUR
<br />U500079952L117A
<br />08/30/2017
<br />08/30/2018
<br />EACH OCCURRENCE $10,000,000
<br />U
<br />Umbrella
<br />AGGREGATE $10,000,000
<br />EXCESS LU1B
<br />CLAIMS -MADE
<br />DED X RETENTION $10,000
<br />C
<br />WORKERS COMPENSATION AND
<br />WA768DO04145777
<br />08 —36-r2 —517
<br />08/30/2018
<br />X I PER STATUTE OTH-
<br />ER
<br />EMPLOYERS'LIABILITY YIN
<br />workers Comp - AOS
<br />E.L. EACH ACCIDENT $1,000,000
<br />ANY PROPRIETOR/ PARTNER I EXECUTIVE
<br />OFFICER/MEMBER EXCLUDED?
<br />N I A
<br />E.L. DISEASE -EA EMPLOYEE $1,000,000
<br />(Mandatory in NH)
<br />If yes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />-_
<br />E.L. DISEASE -POLICY LIMIT $1,000,000
<br />D
<br />E&O-PL-Primary
<br />PSDEF1700460
<br />08/31/2011
<br />08/31/2018
<br />Per Claim $5,000,000
<br />Professional Liab. and CP
<br />Aggregate $5,000,000
<br />n
<br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required)
<br />RE: civic center Stormwater Lift Station Renovation. MB Project No. 167946. Agreement No. A-2016-093 / A-2015-170 / A-2018-177.
<br />".
<br />city of Santa Ana, ROSS Anex is included as Additional Insured in accordance with the policy provisions of the General
<br />Yi�J
<br />Liability policy.
<br />General Liability evidenced herein is Primary/Non-Contributory to other insurance available to an Additional Insured, but only
<br />in accordance with the
<br />rn
<br />policy's provisions.
<br />Should any of the above described policies be cancelled before the expiration date thereof, the policy provisions will govern
<br />how notice of cancellation may be delivered to certificate holders in accordance with the ol" rovisions of each olic .
<br />REVIEWED BY: EUNICE HEREDIA (PG i OF, )
<br />CERTIFICATE HOLDER CANCELLATION
<br />a:-1
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE yl
<br />EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE _+ �'
<br />POLICY PROVISIONS.
<br />City of Santa Ana, Ross Anex AUTHORIZED REPRESENTATIVE &�
<br />20 civic center Plaza
<br />P.O. BOX 1988
<br />Santa Ana CA 92702-1988 USA n/% it p 9f`Gc ' WQ ' p)�iL
<br />©1988-2015 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
<br />
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