|
Pc> 4S31 .) A • 201 'f - 230 • 01
<br />TEROBERT-0
<br />KSHIPPEY
<br />n`oRo CERTIFICATE OF LIABILITY INSURANCE
<br />DATE YY)
<br />08/31/2018
<br />1/201
<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 endomement(s).
<br />PRODUCER License 1110757776 NAONN€ACT Kimberly Shippey
<br />Newport Beach, CA - HUB International Insurance Services Inc. HO°,NE E.t PA
<br />): IA/c No):
<br />4695 MacArthur Court, Suite 600 ..L _
<br />Newport Beach, CA 92660 X A'LR . kimberly.shippey@hubinternational.com
<br />INSURERS AFFORDING COVERAGE NAICN
<br />INSURER A:Old Republic General Insurance Corp. 24139
<br />INSURED INSURER B:Travelers Property Casualty CompanyofAmerica
<br />25674
<br />T.E. Roberts, Inc. INSURER C:
<br />306 W. Katella Ave Unit B INSURERD:
<br />Orange, CA 92867
<br />'._INSURER E:
<br />INSURER F :
<br />COVERAGES CERTIFICATE NUMRFR- RFViginN 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.
<br />INSR
<br />TYPE OF INSURANCE
<br />ADDLSUBRI
<br />INSD
<br />wuD
<br />POLICY NUMBER
<br />POLICY EFF
<br />POLICY EXP
<br />LIMITS
<br />A
<br />X
<br />COMMERCIALGENERALLIABILITY
<br />CLAIMS -MADE [X] OCCUR
<br />X(
<br />AICGI3971800
<br />09/01/2018
<br />09/01/2019
<br />IEACH OCCURRENCE
<br />$ 1,000,000
<br />DAMAGET RENTED
<br />100,000
<br />MED EXP (Any one anon
<br />$ 5,000
<br />PERSONAL SADV INJURY
<br />$ 1,000,000
<br />GEN'L
<br />AGGREGATE LIMIT APPLIES PER:
<br />POLICY X PR -LOG
<br />GENERAL AGGREGATE
<br />$ 2'000'000
<br />PRODUCTS-C_O_MP/OPAGG
<br />2,000,000
<br />g
<br />OTHER:
<br />A
<br />AUTOMOBILE
<br />LIABILITY
<br />_
<br />COMBINED SINGLE LIMIT
<br />o id t
<br />110001000
<br />X
<br />BODILY INJURY (Par Person)
<br />$
<br />ANY AUTO
<br />OWNED SCHEDULED
<br />AUTOS ONLY _ AUTOS
<br />I�
<br />In1CA13971800
<br />09/01/2018
<br />09/01/2019
<br />BODILY INJURY Per accident
<br />$
<br />PROPERTY AMAGE
<br />Per amtlent
<br />_
<br />X _
<br />HIRED X NON -OWNED
<br />AUTOS ONLY AUTOS ONLY
<br />B
<br />X UMBRELLALUIB
<br />XC
<br />I OCCUR
<br />EACH OCCURRENCE
<br />$ 10,000,000
<br />EXCESS LIAR
<br />CLAIMS -MADE
<br />UP-91N03112-18-NF
<br />09/01/2018
<br />09/01/2019
<br />AGGREGATE
<br />$
<br />DELI I X I RETENTION$ 10,000
<br />$ 10,000,.000
<br />A
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS'LIABILITY
<br />ANV PROPRIETOR/PARTNER/E%ECUTIVE
<br />�pFICER/MEMBER EXCLUDED? 11
<br />(Mandatory In NH)
<br />DIf yes,RIPTION describe OFFunder
<br />DESCRIPTION OF OPERATIONS below
<br />NIA
<br />A1CW73971600
<br />_
<br />09/01I2018
<br />09/01/2018
<br />PER OTH-
<br />STATUTE R
<br />E.L. EACH ACCIDENT
<br />$ 1,000,000
<br />E.L. DISEASEEAEMPLOYE
<br />$ 1,000,000
<br />E.L. DISEASE - POLICY LIMIT
<br />$ 1,000,000
<br />DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additions[ Remarks Schedule, may be attached if more apace is requlmd)
<br />Re: Agreement for #8208;On Call Sewer and Water System Repair Services throughout the City of Santa Ana, CA
<br />City of Santa Ana, its officers, employees, agents, volunteers and representatives are included as additional insureds, as respects general liability, which is
<br />primary and noncontributory, subject to the terms and conditions of the policy, and attached forms. 30 days notice of cancellation, 10 days for non-payment
<br />of premium.
<br />v
<br />Af S
<br />City of Santa Ana
<br />Public Works Agency -Water Resources
<br />220 S. Daisy M-85
<br />Santa Ana, CA 92703
<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 />J4-
<br />AULIKU ZO (ZUTDIUJ) (p)1938-2015 ACORD CORPORATION. All rights reserved.
<br />The ACORD name and logo are registered marks of ACORD
<br />
|