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A� ®® CERTIFICATE OF LIABILITY INSURANCE
<br />DAB/3/201
<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 pollcy(les) must be endorsed. If SUBROGATION IS 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 -
<br />CONTACT Peggy Coleman
<br />Brown & Brown Insurance Services of CA, Inc.
<br />p/C NNo PcI, (714) 221-1800 FAC Not(734)221-4196
<br />2401 E. Katella Ave.
<br />ADDRESS,pcoleman@bbsocal.com
<br />Shite 550
<br />INSURERS) AFFORDING COVERAGE
<br />NAIC#
<br />INSURERA:State National Insurance Company,12831
<br />Anaheim CA 92806
<br />INSURED
<br />INSURERB:RSUI Indemnit;y Cc
<br />22314
<br />INSURERC:State Compensation Insurance Fund
<br />35076
<br />The W Corporation, DBA: Vantage Company
<br />INSURER D.Darwin Select-AWAC
<br />19489
<br />1643 W Orange Grove Ave
<br />INSURER E:
<br />MED EXP (Any one person) $ 5,000
<br />INSURER F:
<br />Orange CA 92868
<br />COVERAGES CERTIFICATE NUMBER:CL1762836810 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 NTH 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 />ILTR
<br />TYPE OF INSURANCE
<br />INSID ADOLS
<br />O
<br />POLICYNUMBER
<br />POLICY EFF
<br />MMI�DIYYYY
<br />LIMITS
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />EACH OCCURRENCE $ 1, 000, 000
<br />A
<br />CLAIMS -MADE �X OCCUR
<br />PREMISES Ea occurrence $ 100,000
<br />X
<br />MED EXP (Any one person) $ 5,000
<br />Ded: $5,000
<br />XHDP0229100
<br />12/31/2016
<br />12/31/2017
<br />BI/PD Combined
<br />PERSONAL &ADV INJURY $ 1,000,000
<br />AGGREGATE LIMIT APPLIES PER:
<br />GENERAL AGGREGATE $ 2,000,000
<br />GEN'L
<br />POLICY PRO-
<br />JECT 1:1 LOC
<br />PRODUCTS COMPIDP AGG $ 2, 000, 000
<br />Employee Benefits $
<br />OTHER'.
<br />AUTOMOBILE LIABILITY
<br />_
<br />10BINEDSINGLE LIMIT $ 1,000,000
<br />Ea accident
<br />_
<br />BODILY INJURY (Per person) $
<br />A
<br />X ANYAUTO
<br />ALL OWNED SCHEDULED
<br />AUTOS AUTOS
<br />XRDA0229100
<br />12/31/2016
<br />12/31/2017
<br />BODILY INJURY (Per awlldenq $
<br />X HIRED AUTOS X NOTOSMED
<br />Per PERT^DAMAGE $
<br />Underinsured opa.t $
<br />UMBRELLA LIAB
<br />X
<br />OCCUR
<br />EACH OCCURRENCE S 5 000 000
<br />AGGREGATE $ 5,000,000
<br />B
<br />X
<br />EXCESS LIAB
<br />CLAIMS -MADE
<br />DEO I X I RETENTION$ 0
<br />$
<br />NRA241739
<br />1/5/2017
<br />12/31/2017
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY YIN
<br />__70
<br />X PER -
<br />STATUTE ER
<br />C
<br />ANY PROPRIETORPARTNERIEXECUTIVE
<br />OFFICERIMEMBER EXCLUDED?
<br />(Mandatory In NH)
<br />NIA
<br />921338317
<br />7/1/2017
<br />7/1/2018
<br />E. L. EACH ACCIDENT $ 1,000,000
<br />E.L. DISEASE - EA EMPLOYE $ 1 000 000
<br />If yes, describe under
<br />DESCRIPTION OF OPERATIONS be.
<br />E.L. DISEASE -POLICY LIMIT $ 11000,000
<br />Professional Liability
<br />$5, 000,000 Ea Calm
<br />D
<br />lPer Claim Retention:$10,000
<br />03052628
<br />1/16/17
<br />1/16/18
<br />$5,000,000Aggregate
<br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required)
<br />City of Santa Ana, it's officers, employees, agents & representative are included as additional insured
<br />as required by written contract as respects general liability regarding the operations of the named
<br />insured. Form CG20100413. 30 day Notice of Cancellation regarding general liabitly & auto liability
<br />applies per Form IL12011185.
<br />CERTIFICATE HOLDER CANCELLATION
<br />ACORD 25 (2014/01)
<br />INS025 (201401)
<br />©1988-2014 ACORD CORPORATION. All rights reserved.
<br />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
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />20 Civic Center Plaza
<br />ACCORDANCE WITH THE POLICY PROVISIONS,
<br />Santa Ana, CA 92701
<br />AUTHORIZED REPRESENTATIVE
<br />C Morse/PCOLEM �
<br />ACORD 25 (2014/01)
<br />INS025 (201401)
<br />©1988-2014 ACORD CORPORATION. All rights reserved.
<br />The ACORD name and logo are registered marks of ACORD
<br />
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