|
A' 2-014.23u.oI
<br />CERTIFICATE OF LIABILITY INSURANCE
<br />E (MMIDD
<br />IN
<br />DATE/31/2097 YI
<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 Patriot Risk & Insurance Services
<br />2415 Campus Drive, Suite #200
<br />Irvine, CA 92612
<br />CONTACT
<br />NAME
<br />PHONE o E. sas 486-7900 a Na: sas assasso
<br />E-MAIL
<br />ADDRESS:
<br />INSURER(S) AFFORDING COVERAGE
<br />NAICN
<br />_
<br />INSURER A: Valley Fore Insurance Company
<br />20508
<br />www.patrisk.com OK07568
<br />INSURED
<br />T. E. Roberts, Inc.
<br />306 West Katella Avenue
<br />INSURER B: Continental Casualty Company
<br />20443
<br />INSURER c: Liberty Mutual Fire Insurance Company
<br />23035
<br />INSURER D:
<br />Unit 'B'
<br />Orange CA 92867
<br />INSURER E:
<br />INSURER F:
<br />COVERAGES CERTIFICATE NUMBER: 37525643 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.
<br />INSR
<br />LTR
<br />TYPE OF INSURANCE
<br />ADDL
<br />SUBR
<br />POLICYNUMBER
<br />POLICY EFF
<br />MMIDDIYYYYI
<br />POLICY EXP
<br />MIMIC
<br />LIMITS
<br />A
<br />✓
<br />COMMERCIAL GENERAL LIABILITY
<br />✓
<br />6014373100
<br />9/1/2017
<br />9/1/2018
<br />EACH OCCURRENCE
<br />$ 1,000,000
<br />❑✓ OCCURA
<br />ET RENTED
<br />UAMCLAIMS-MADE
<br />PREMISES Ea occurrence) IE enoe
<br />$ 300,000
<br />✓
<br />MED EXP(Any one person)
<br />$ 5,000
<br />$5,000 Deductible
<br />PERSONAL &ADV INJURY
<br />$ 1,000,000
<br />AGGREGATE LIMIT APPLI ES PER.
<br />GENERALAGGREGATE
<br />$ 2,000,000
<br />GEWL
<br />POLICY JEo LOD
<br />PRODUCTS - COMP/OP AGG
<br />$ 2,000,000
<br />$
<br />OTHER'
<br />B
<br />AUTOMOBILE
<br />LIABILITY
<br />6014373114
<br />9/1/2017
<br />9/1/2018
<br />COMBINED SINGLE LIMIT
<br />accident)
<br />$Ea 1,000,000
<br />BODILY INJURY (Per person)
<br />$
<br />✓
<br />ANY AUTO
<br />OWNED SCHEDULED
<br />AUTOS ONLY AUTOS
<br />BODILY INJURY (Per accident)
<br />$
<br />HIRED '0'✓
<br />AUTOS ONLY ✓ AUTOS ONLY OWNED
<br />OTY
<br />Perr aa�ntlDAMAGE
<br />$
<br />S
<br />A
<br />✓
<br />UMBRELLALIAB
<br />✓
<br />OCCUR
<br />6014373128
<br />9/1/2017
<br />9/1/2018
<br />EACH OCCURRENCE
<br />$ 6000,000
<br />AGGREGATE
<br />$ 6,000,000
<br />EXCESS LIAB
<br />CLAIMS -MADE
<br />DELI RETENTION$
<br />$
<br />C
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS'LIABILITY YIN
<br />ANYPROPRIETORIPARTNERIEXECUTIVE ❑
<br />OFFICER/MEMBER EXCLUDED?
<br />NIA
<br />WC2Z91459902047
<br />9/1/2017
<br />9/1/2018
<br />✓ SPER TATUTE OTRH-
<br />E.L. EACH ACCIDENT
<br />$ 1,000,000
<br />EL. DISEASE - EA EMPLOYEE
<br />$ 1,000,000
<br />(Mandatory in NH)
<br />If yes, describe under
<br />DESCRIPTION OF OPERATIONSbelm
<br />E.L. DISEASE -POLICY LIMIT
<br />$ 1,000,000
<br />DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached If more space Is required)
<br />Re:Agreement for 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 named as Additional Insureds, includes Primary and
<br />Non-contributory as respects to General Liability per endorsements attached where required by written contract.
<br />30 days notice of cancellation, 10 days for non-payment of premium.
<br />YL,PA 1,C,IDfi
<br />City of Santa Ana
<br />Public Works Agency - Water Resources
<br />220 S. Daisy
<br />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 />AUTHORIZED REPRESENTATIVE
<br />E.
<br />All H.Into rmnevnd
<br />ACORD 25 (2016103)
<br />The ACORD name and logo are registered marks of ACORD
<br />31525643 1 17/18 GL/AU/UMe/WC I Mnette Romero 1 8/31/2017 1W5:51 AM PUT) I Page 1 of 15
<br />This cettifica[e cancels antl supecsetles ALL previously issued certificates.
<br />
|