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KAPSCH TRAFFIcCOM TRANSPORTAITON NA, INC. (FNA SCHNEIDER ELECTRIC MOBILITY NA, INC. 3b - 2016
TI r 1111RANOI ON RILE WORK MAY PROCEED UNTIL INGUR ZOE EIDI ES CLERK OF COUNCIL DATE JI)L 2 1 ?016 FIRST AMENDMENT TO CONSULTANT AGREEMENT D� THIS AGREEMENT is made and entered into this 15th day of June, 2016, by and between Kapsch TrafficCom Transportation NA, Inc., a Michigan Corporation (formally known as Schneider Electric Mobility NA, Inc.) and the City of Santa Ana, a charter city and municipal corporation organized and existing under the Constitution and laws of the State of California ("City"). RECITALS: A. The parties entered into Agreement # A-2D16-057, dated April 6, 2016 (hereinafter C said Agreement"). U. On April 11, 2016 Schneider Electric Mobility NA, Inc, changed its name to Kapsch TrafficCom Transportation NA, Inc., A Michigan Corporation, e WHEREFORE, in consideration of the covenants contained in said Agreement, and subject to all the terms and conditions of said Agreement, except those amended in this First Amendment to the Agreement, the parties agree as follows: 1, Said Agreement is hereby amended by substitution of the name "Schneider Electric Mobility NA, Inc." for the name "Kapsch TrafficCom Transportation NA, Inc." wherever it appears in the Agreement. I 2, Except as hereinabove amended, all terms and conditions of said Agreement shall remain in full force and effect. IN WITNESS WHEREOF, the parties hereto have executed this Agreement the date and year first above written. ATTEST: MARIA D, HUIZAR CI Clerk of the Council SONIA R. CARVALHO City Atforney(' -/ DOVAL tant City Attorney CITY OF SANTA ANA DAVID CAVAZOS City Manager Executive Director Public Works Agency CONSULTANT Kapsch TrafficCom Transportation NA, Inc p( Tax ID# �01 A/""" h� /lw CERTIFICATE OF LIABILITY INSURANCE DATE ( YYYY) 11I30/2016 12016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER MARSH USA, INC.[ 99 HIGH STREET- CONTACT NAME: _ PHONE FAX (A/C, No Ext): (A/C, No): BOSTON, MA 02110';1 Attn: Boston.certrequest@Marsh.com Fax: 212-948.4377 EMAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC # INSURER A: Federal Insurance Company 20281 116924947-all-GAWU-16-17 INSURED Kapsch TrafficCom Transportation NA, Inc: 8201 Greensboro Drive:' INSURER B : Great Northern Insurance Company '.20303 _ Chubb Indemnity Insurance Company 12777 INSURER c : Y P y INSURER D : Suite 10021' Mclean, VA 22102 — -- --- INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: NYC-008687448-01 REVISION NUMBER:O THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN RrEDUCED BY PAID CLAIMS. IXP �TR TYPE OF INSURANCE ADDL SUER POLICY NUMBER EFF I MM/DD/YWY MM/DDIPOLICY YEYYY LIMITS A X COMMERCIAL GENERAL LIABILITY 9949-16-74 11/30/2016 11/30/2017 EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE T OCCUR DAMAGES( RENTED PREMISES Ea occurrence) $ 1,000,000 MED EXP (Any one person) $ 10,000 _ PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY El PRO- JECT ❑ LOC PRODUCTS - COMP/OP AGG $ 2,000,000 $ OTHER: I B AUTOMOBILE LIABILITY 7356-51-01 11/30/2016 11/30/2017 (CEO MBINED SINGLE LIMIT accident $ 1,000,000 BODILY INJURY (Per person) $ X ''. ANY AUTO '.. ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ X HIRED AUTOS X NON -OWNED AUTOS PROPERTY DAMAGE Per accident $ A X UMBRELLA LIAB �'.. X OCCUR 7983-64-37 11/30/2016 11/30/2017 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 EXCESS LIAB CLAIMS -MADE DED RETENTION $ $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED' 7N N / A (17)7175-13.28 11/30/2016 11/30/2017 X STATUTE �RH "-" E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below --- E.L. DISEASE- POLICY LIMIT $ 1,000,000 RE-IWYWEf1 E1Y__._ F tl4 f-EMA(FG Ckl` p _ NW^EUNIC DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) City of Santa Ana, PWA - Transportation & Traffic Engineering Department are are included as additional insured (except for Workers Compensation) where required by written contract. Waiver of Subrogation is applicable in favor of City of Santa Ana, PWA - Transportation & Traffic Engineering Department on the General Liability, Auto Liability, Umbrella Liability, and Workers Compensation where required by written contract. CERTIFICATE HOLDER CANCELLATION City of Santa Ana:! Attn: Vinh Nguyen, RE., Sr. Civil Engineer. PWA - Transportation & Traffic Engineering,: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 20 Civic Center Plazas. Santa Ana, CA 92701 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Elizabeth Stapleton ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD Endorsement Policy Period NOVEMBER 30,2016 TO NOVEMBER 30,2017 Effective Date NOVEMBER 30,2016 Policy Number 9949-16-74 DTO Insured KAPSCH TRAFFICCOM HOLDING 11 US CORP Name of Company FEDERAL INSURANCE COMPANY Date Issued DECEMBER 14,2016 This Endorsement applies to the following forms: , ;QW.T.180411-3 Under Who Is An Insured, the following provision is added [WIT -If X., U75 =7 I Additional Insured - Persons or organizations shown in the Schedule are laswreds, but they are insureds only if you are Scheduled Person obligated pursuant to a contract or agreement to provide them with such insurance as is afforded by Or Organization this policy. However, the person or organization is an Imured only: • if and then only to the extent the person or organization is described in the Schedule, • to the extent such contract or agreement requires the person or organization to be afforded status as an Insured; • for activities that did not occur, in whole or in part, before the execution of the contract or agreement; and • with respect to damages, loss, cost or expense for injury or damage to which this insurance applies. No person or organization is an hwared under this provision: • that is more specifically identified under any other provision of the Who Is An Insured section (regardless of any limitation applicable thereto). • with respect to any assumption of liability (of another person or organization) by them in a contract or agreement. This limitation does not apply to the liability for damages, loss, cost or expense for injury or damage, to which this insurance applies, that the person or organization would have in the absence of such contract or agreement. Liability Insurance Additional Insured - Scheduled Person Or Organization Form 80-02L2367(Ray. 5-07) Endorsement continued Page I 1) BY� EUNICE HEREDIA (Pc� OF Liability Endorsement (continued) Under Conditions, the following provision is added to the condition titled Other Insurance. Other Insurance — If you are obligated, pursuant to a contract or agreement, to provide the person or organization Primary, Noncontributory shown in the Schedule with primary insurance such as is afforded by this policy, then in such case Insurance — Scheduled this insurance is primary and we will not seek contribution from insurance available to such person Person Or Organization or organization. Schedule Persons or organizations that you are obligated, pursuant to a contract or agreement, to provide with such insurance as is afforded by this policy. All other terms and conditions remain unchanged. Authorized Representative Q, - - A �-' -1 a Lability Insurance Additional Insured - Scheduled Parson Or Orgenizaffon Form 80-02-2367 (Rev. 5-07) Endorsement 1.REVIEWED BY EUMCEFIEREMA(PG orw�) - ..... ....... . .....-.5 - , --] FN `C� D CERTIFICATE OF LIABILITY INSURANCE nA7120MM1OaIYYYYf THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPO1. N THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER, IMPORTANT: If the certificate holder Is an ADDITIONAL.INSURED, the polley(las) must be endorsed, If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement n , PRODUCER MARSH USA INC. 99 HIGH STREET BOSTON, MA 02110 Attn: Sastnn.CeRRequesk(�Mareh•com I Fax; 212.948-4377 O E' PHONE P X (A/C, .MAIL S INSURERS AFFORDING COVERAGE NAIC IA DWEIS INSURER A: Notional Union Fire Insurance Company 19446 INSURED Schnalder Elaotrlc Haldinga, Inc. INeUREA s I Now Hampshire Insurance Co, 23841 INSURER c I I-DbGerling Amedca Insurance Company 41343 (See page 2 for Addltlenal Named hemostat 200 odh Matilin Is Road, Suite 1000 Sohaumi urg, It. 0173 INSURER o: Illinois National Insurance Com any -- 23817 NSU OR a: THIS IS TO CERTIFYTHAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE 'TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCE[) BY PAID CLAIMS. L79E TYPEOPINSURANCE R mm, POLICYN NUMBER RMIOO YYEPV OL YVI LIHtIT8 A X COMMERCIAL GENERAL LIA131LITY CLAIMS -MAW [71 OCCUR ConUaCtUBI Liablllly X X 2039174 0110112010 0101/2017 EACH OCCURRENCE — $ 61000.000 �E�q MED EXp (Any ana,,,8oreon $ 6,000,000 X $ 6,000 PERSONAL A AOV INJURY -$ 6,000,000 GENT. AGGREGATE LIMIT APPLIES PER X POLICY ❑PRO- F]OC ECT GENERALAGGREGATE $ 610001000 - PRODUCTS-COMP/OPAGG a 6,000,000 $ OTHER: A S g AUTOMOBILE X . LIABILITY ANY AUTO ALL OWNED SCHEDULED AUT08 AUTOS HIREDAUTOS AUT09 EO AUTOS X X 9734260(AO$) 9734264(MA) 9734265(VA) 01101/2016 01/0112018 0110112016 0110112017 0110112017 0110112017 COMEINED8IN-L /MIT 191=11bntl _ BODILY INJURY (Per parson) a 5,000,WO $ BODILY INJURY (Pe Aooldont) $ ROP9- YPAM E W- — X �^ UMBNELLA LIAR EXCESS LIAR .OEQ X I OCCUR CLAIMS -MADE O11D11800-04 01/0112010 0110112017 EACH GCCURRENOE $ 5,000,00c — AGGREGATE �-` $ 61000,000 E E ION. -� X PE "PJTH• ST ER NIA ( 068022490(ADS) Ad(I100nal WGEL policies are shown on thefnliowln g page 0110112010 0110 2 7 B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORRARTNERIEXECUTIVE OPFIGER/MEMDER EXCLUOE07 rhl Nlq If' Iryae daearlbuunder DLy-'S(HRIPTIO OP OPEPATIO A E,L•EACH ACCIDENT $ 5,000,000 E.L. DISEASE -EA EMPLOYEE $ 6,000,000 E,L.❑IBEASE-POLIL'YLIMIT $ 6,000,000 B PROFESSIONAL 03-206-10.99 01/0112016 01101120'17 EACH CLAIM/AGGREGATE 6,000,000 E&0 LIABILITY - POLICY IS CLAIMS MADE DESCRIPTION Or, OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional RBMMM SUMIM101 may ha attAPhod If more space Is ragelred) Re: Schneider Electric Moblity NA, Ina City of Santa Ana, PWA-Transponatlon & Traffic Engineering Department are Included as additlonal Insured with respect to General and Auto Uablllly. This Insurance Is primary and non-contrlbulory over any existing Insurance and limited to Ilablllty arising out of the operations of the named Insured for General Uablllly, and Automobile Uablllly, Welvar of Subrogalloo Is Indudad In favor of the Oerlltloato Holder under General Labllliy, Auto Uablllly, and ftrkoes COMpan 110R. EUNI,GF r;tE E®IA (PG,J of Oily of Santa Ana Alin; Vfnh Nguyen, RE, SL Civil Engineer PWA -Transponatlon & Trade Engtnaering 20 CNic Center Plaza Santa Ana, CA 92701 SHOULD ANY OF THE ABOVE DE801`06ED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Ina, Sarah A. Stevenson Aa"4a. hnhfa AOUMU zo (ZU14191) The ACORD name and logo are registered marks of ACORD AIIC RH AGENCY CUSTOMER ID, _838732 LOC 0: Boston ADDITIONAL REMARKS SCHEDULE Page 2 of 3 AGENCY MARSHUSA INC, NAMEDINSURED _-- — Sahnelder FlealrlD Holdinggs Ina. (Sea ppage 2 for Addlllorm f3amed Insureds) 200 NDrlh Madingala Road, Bulls 1000 Schaumburg, IL 60173 POLICY NUMBER - CARRIER NAIC CODE B7rECTIVE CATS; THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 26 FORM TITLE: Certlfloate of l.lablllt_ y Insurance ADDITIONAL NAMED INSUREDS INCLUDE THE FOLLOWING: Schnelder Eleatdo IT Corporation Schnelder Flsotdc IT USA, Ina, AST North Amass, LLC Sohnclder Eleotrlo IT Amerloa Corp, GRC Energy 8upporl Servlese, LLC Invonsys Systems, Ina. Invensys Systems, no, doe Solmsloer Pleofrlo Systems USA, Ina, Invonays Syslema, Inc, sea Suhnelder Eloetrlo Systems USA Induao0, Ina. - InStep Software, LLC Schneider Eleotrlo IT Mlsslon Critical Servlaea, Ina. Petra, Ina. Pro -Face Aeration, LLC Schnelder Electric Bulldings Ameticsia Inc. Sohnclder Eleclrlo BUIMIngs Crllimel Systems, Ins. Sohnclder Electric SUlltlings, LLC Sohnclder Efealdo Power Sarvlees, Ina, Schnelder Eleotrlo USA, Ina, Sclmoder Eleotrlo Enufneering Servlaes, LLC Sohnelder Electra Motlon USA, Ina. Scnnelder Electric Software, LLC Sohnalder Eleotrlo Solar Invaders, USA Summll Energy Serwoes, Inc, Talon( USA, LLC Sahnelder Eleotrlo Moblllly, NA, Inc. Telvenl DTN, LLC Verls MIMIC% LLC "ADDITIONAL WORKERS COMP POLICIES - CARRIER: NEW HAMPSHIRE INSURANCE COMPANY POLICY PERIOD: 01(01110 � 01/01117 POLICY NUMBERS AND STATES: WC 08802200 (AL, AR, CO, CT, DO, DE, GA, 111, (A, ID, IN, KS, LA, MD, MI, MO, MS, MT, NE, NM, NV, NY, ON, OR, RI, SC, SD, TN, TX, WV) WC 000022403 (CA) WC 000022498 (FL) WC 068022404 (MA,ND,OH, WA,WI,WY) WC 060022491 (MN) WC 068022490 (IL, KY, NC, Nht, UT, VT) WC 080022497 (NJ, PA) WC 080022492 (ME) WC 008022495 (AT, VA) PUERTO RICO, WC IS PURCI ASED THROUGH THE STATE FUND AS PUERTO RI CO 18 MONOPOLISTIC, REVIEWED BY, q . EUfVICE H? REDtlA,(Pc. OF 6 ACORD 1(2008101) 0 2008 ACORD CORPORATION. All rights raaavvad The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 08732 LOC 1Fr Boston ADDITIONAL REMARKS SCHEDULE Page 3 of 3 AGENCY NAMED INSURCD MARSH USA INC. Schnelder Electric Holdings, Inc. See ppa�a 2 for Addlllonal Named Insureds) 0o Nadh Martingale Road, Suite 1000 POLICY NUMBER Schaumburg, IL 60173 OARRIER NATO CODE EFPECTIVC DATE: THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ___.26 _-._ FORM TITLE:.Certlfloate of Liability Insult OHIO ONLY EXCESS WORKERS COMP; CARRIER; NATIONAL. UNION FIRE INSURANCE COMPANY POLICYPERIOD 01f01110.01101117 POLICY NUMBER: 1103534 LIMITS: EACH ACCIDENT: $3.000,0001 DISEASE -POLICY LIMIT! 3.000,0001 DISEASE -EACH EMPLOYEE: $3,000,000 SELF -INSURED RETENTION: $2,000,000 Umbrella Llablllly Polloy follows underlying on Additional Insured and Waiver of Subrogaton Schneldar Electric Holdings, Inc, has agreed than, within 30 days after tacelptof notice of cancellation of the Insurance policlos roforenced above from the applicable Insurers, Schneldar El6010 HoMinge, hla, or Its designee wilt send a o0py of such notice to the Cerllgeata Holder of ME Carflflaato, Such notice Is note right or obllgaton wthln the poiclas, it does not snorer amend any coverage, It will not extend any pollcyoanoelladon dale and It will not negate any cancellation of the pollsµ Falluro to provldo a copy of such notoo to the Cerglion le Holder shell Impose no ohllgatlon or liability of any kind upon the Insurer or Its agonls or representatives 0 2000 ACORD CORPORATION. All rialits reseru I NO ACORN name and logo are registered marks of ACORN Thls andorsemant; sheaths 1201 AM, 9 i:tpt:r9pi:+� taama a pastas poNioy NO, 00 38=49V FJ Issued to.. FtC �' by u� !°sussaurarai�m t mr� ui �c cats _a �t sau it:,�u v 'THIS PIND RIPPM151T CHMOR THE PMICY, PLeAsm ITS IT GAREPULLY Wo NV A OF T Op H OF MGHT'S OF RECOMY AGAINST OTHER To US Trays padomoMant enodNev rrrsuranan pirvtdad Under t% rojowJaOr Neptyom IV . Business Auto Conditions, A, . Low4 Conditions, S.. Tmnstar of Rights of 1Tgaovasy ninst Offiars to tih, to amended to actdx i OWOvar, we +aNNN waive Any right Of raaaver we have apainet any parudn or drg8*61100 Wiii) when) you have Ofiterad rota a cOnNrnst Or dprgarntant haahuaa of paya ants we make War ti)is 0ovempa Farm sde3lnp out of an 0awwoor at "logs" it, (1) The ®aasidentf' or "loan" Nu due to cpdr*jQA$; undedaiton to occordarlog with the contrast anistiaap hOWOOn you and such semen or and ) Taho pur "at or arNa a ent w a aritdrrast isogo pdrsr bt any "aasldarn" or wse» No waver of the dpht of Mavery WWII atlreogy or IndisedCy apply tp your gavapiOyaaa Or emAiayseq of the parson or mijanrration, and eta reserve Our rtiitiiu or Niaq to be raimbumad trove pq rerwary !undo ubtwnud y any injured amysioyao. 11Y�3>M7i%T�lTd' This endorsernent, affective 12,01 ArM, 0101120% forma a part of policy No, GL 203.91.74 Issuedta, SGHNEIDER CLMCTRIC HOLD INOS, INC, by NATIONAL UNION FIRE: INSURANCE COMPANY OF PIUSSUROH, PA THIS ENDORSEMENT CHANQ1$ THE POLICY, PLEASE READIT CAREFULLY ADDITIONAL INSURED - PRIMARY INS,URMCC 7hN endorsement mcdarlas lbourancs prnwlded under dhs t1lowfrtg,' COMMERCIAL GENERAL LAKI'TY COV RAGS FORM. 4e0110n IV, ComMerclal General Liability Conditions, paragraph A„ Oltber In.sumnca, pU13119 agrpplt a, I''rtmaty Intura4pa,. is amended by the addiflpn of the following: However, poverade under this policy afforded to an, additional ineurad wlli apply as prin cry insurances where required by contract, and any Other inauranea 1,01,1 d to such additional insured shall apply as excess and noncontributory Insurancg, 7404 (10199) PMIOY NUMBER; OL 2030174 COMMERCIALiPoRNINAd.L LIABILITY 0090100413 R �w T1114 andoreOMOht nr0411104 Insurance provided under the followkna, COMMERCIAL GrANE RAL WAC3N ITY 0OVERAQN PART A. $eabon II — Who Is An Insured la amended to Inoluda as an additional Insured the poraon(s) or organl2atBon(s) shown In fire Sohedule, but only with respect to liability for "hcdlly Injury', "property clamogo" or ^personst and advorgoing Itjury" caused, in whole or in part, by: 1. Your sots or,ornlselons; or 2. The anta or orniosions of those acting on your behalf; In the padormanoe of your orngeing oporabooa for the addrdrafW ifeurad(s) at the iattation(s) dos gnated abovs, However, 1. the Irrsurenaa afforded to such addidonst Insurac! only applies to the extent permldod by low; and 2. 1'1'covenago provided to'tho additional Insured is required by a oontrat or aggreement, the inaurentre afforded to such additional Insured will runt be broader than that which you are required by the oontraot or agreement to prcVlda for Such additional Insured, t, With MepeeI to the inauronoe afforded to these ar}ddtionel inaurads, the following is added to $action tt1— Limits or losuranow If ooverapa proAded to the additional Insured is Nwit{uIred dyy e contract or agreement, the most we pay an behalf of the additional Insured Is ins amount of Ineurenos; 1. Ragtalred by the rauntroot or agreement; or M With respect to the Insurance afforded to these additional Inaurads, the following additional exclusions apply: This ineurenoo does not apply to "bodily Injury"' or "Property domape° oaourratt after; 1. All work, Including materials, parts or egtaipmeot hrrnioNd in connootlon with ouch crorlt, on the project (other then service, matntananoa or repairs) to be perfmrnod by or an behalf of the additional Pnsurod{a) At the location of the covwed operations hsa boon completed; at 2. That portion of "ytaua" work" out of which: the Injury or damogo srtsos has bearr put to it$ Intended use by any person or onflonl2atign Other than another contractor or subcontractor angaged In parfuoning operations for a pr1ncipal as a part of the same project, 2. Available under the appliobto Limits of Inauranda shaven in the Ueatarwlomr; whiohavar is tea9, This ondoreement shall not Inorease the applicable Unfits of Insurance shown in the 0eaalaraalions. POLICY n;Gt, 203-91-74 COMMERCIAL GENERAL C 24 04 1. 0,11 WAIVER OF TRANSFER .. RIGHTS OF RECOVERY , AGAINST OTHERS TO US This end=Onn llf modifies Insurance provided under tho.followingi COMMERCIAL" foENERAL t IA811.17'Y COVERAGE PART PF2ODUOTWCOMPI E'TED OP RAWNS UABILITY.CUVEnA e PART WHIVIDULE Narnra Qfi i�raraon TJr brgsnlseafian; ANY PERSON OR ('=AhIZATION: REQUIRING A WAIVE;R.Ch TRANSFER OF RIcHrra or RECf VeRY PURSUANT TO THE TERMS OF ANY CCNTRA�T OR A WEM NT YOU ENTER INTO WITH SUCH PERSON OR ORGANIZATION The following is added to Psrag(aph 8, Transfer of tights Of ROcorvery Against Others To Us of 60tion IV — Conditions; We waive any right of recovery we my hava sgWnst tine parson or organization shown In the Schedule above because of paymmnN we n%ke for Injury or damage prising out of your ongoing operations or "Your work" dons under a €:ontraat witia that person or oiry ,snizaklon end Included 10 Ole "products• Wmpieted operations htuard This waiver applies only 'to the person or organization shown in the 8..ohedule above, CO 24 04 p : 00 0 Insuranoe $$Nice* office, haw„ 2,08 / Psg0I. of f BLANKET WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT This endorsement changes the Polley to whloh it Is WWI* effective on the inception, date of the policy unless s different date is iltdfbated below, (rho) failowma ":attnohlntt olnuae" need be Completed only when 111ie eo(jursomont ID Innuatl eubeaepaent 90 prpperetiurt or tho policy), This endorsement, effootive 12:01 AM 011DI 12016 forme a part of Policy No. WC 06 .-02»2aigj Issued toSCHNEIDER ELECTRIO HOLDINGS, INC. BYHEW HAMPSH I RE INSURANCE COMPANY We have s right to recover our payments from anyone liable for an ln)ury covered by thla pallcy. We will not enforce our right against any peroon or Organization with whom you have S wdW contract that requires you to Obtain theta agreement from us, as regards any work you perform for such peNon or organization. The additional premium for this endorsement shell be 2.00 % of the total estimated workers compensation prernium for this policy. RUC 04 03 CM counterslanoo by ............ ...._ _ � ".. "G' �h (pd' 1'1100) Authorized Reprosentautivo A�C"R" CERTIFICATE OF LIABILITY INSURANCE 04/26/20 6 YY� THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Marsh USA Inc., Multinational Incoming Unit a service of Seabury and Smith, Inc. 9830 Colonnade Boulevard, Suite 400 PHONE FAX A/C No Ext:210-691-9100 A/C No:210-737-3584 E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC# PO Box 659520 San Antonio, TX 78265-9520 INSURER A: FEDERAL INSURANCE CO 20281 INSURED INSURER B: CHUBB INS CO OF CANADA Kapsch TrafficCom Transportation NA, Inc INSURER C:ACE American Insurance Co 22667 8201 Greensboro Drive McLean, VA 22102 INSURERD: INSURER E: INSURER F : I04011T171L111n 3. Fl=rag In IMA\r=dnNutl_1=!,]d1/Ly r615■\IIIJ,Ie73 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF MMIDDIYYYY POLICY EXP MM/DDIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE E OCCUR 99991674 ;, a t.a,ovzala 11./30/201c EACH OCCURRENCE $1, 000, 000 PREM SES� a occu ence $1, 000, 000 MED EXP (Any one person) $10 , 0 0 0 PERSONAL &ADV INJURY $1, 000, 000 GENT AGGREGATE LIM] T AP PLIES PER: GENERAL AGGREGATE $2,000,000 X POLICY C PRO JECT ❑ LOC PRODUCTS - COMP/OP AGG $2, 000, 000 $ OTHER: A AUTOMOBILE LIABILITY 73565101 p4/011/-016 11 /:30/2016 B'NED CEa accidenOM.,d.ntSINGLE LIMIT $1,000,000 X ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE Per accident $ B X UMBRELLA LIAB X OCCUR 79872350 04/01/2016 11130120.16 EACH OCCURRENCE $5,000,000 AGGREGATE $5, 0O0, 000 EXCESS LIAB CLAIMS -MADE DED RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN 71751328 04/01/2015 _1/30;2616 PER OTH- STATUTE ER E.L. EACH ACCIDENT $1, 000, 000 ANY PROPRIETOR/PARTNER/EXECUTIVE D? OFFICER/MEMBER EXCLUDE N / A E.L. DISEASE - EA EMPLOYEE $1, 000, 000 (Mandatory in NH) If yes, describe under DESCRIPl10N OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $1, 000, 000 C Professional E01MG25.590144003 04101/2016 .130/2016 Limit 5,000,000 E & 0 Claims Made Aggregate 5,000,000 Retro Data 06/01/11 Retention In, 000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Umbrella Liability policy 4 3,723'5C with Chubb C.cimpany of. ,anada was played Ly March Canaria Limited. Seabury & Smith, Inc. has only acted in the role off a consultant `o the client ith respecr to this placement which is placed here for your convenience. City of Santa Ana, PWA - Trrnsportat:ion & Tt:af:fi� Erigmeer.ing ❑epartment ar.. are -n_L"Id d as Additional. on the General Liability, Auto Liability and Umbrella Liability policies as required by written contract. Waiver of Subrogation is Lr favr_r if City t ant.i Ana, PWA f an..p� i`ian & Tra i trJLnr.. ing D2par.merit on the General Liability, Auto Liar tirnbrelli Liability and lw rkers compan.a.atron po_-_i-s -7r r. qu 3rrcl 1r, 1tten contrFc,,t. .-____.._.._....__....__..,... _ T.._.__._..__ _ _.....,____.._ ..._ REVIi».WED B a' EUNI CE HE REDIA (PG nil-- Vcm i Ir n-K I c I'IVLIJcm City of Santa Ana Attn: Vinh Nguyen, P.E., Sr. Civil Engineer PWA - Transportation & Traffic Engineering 20 Civic Center Plaza Santa Ana, CA 92701 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORI D REPRESENTATIVE 0 bNa�,_kv ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD DS#66249591 I " 11� =Z Endorsement Policy Period Effective Date Policy Number Insured Name of Company Date Issued This Endorsement applies to the following forms: CAHNFRAL LIABILITY NOVEMBER30,2015 ID NOVEMBER.30,2016 NOVEMBER 30,2015 9949 16.7,l ("]A.B KAPSCHTPAHICCUN/1 HOLDIM] If US COR11 FEDERAL INSURANCE CONWANY DECEMBER 7, 2015 Under Who Is An Insured, the following provision is added. Additional Insured - Persons or organizations shown in the Schedule are insureds; but they are insureds only if you are Scheduled Person obligated pursuant to a contract or agreement to provide then) with such insurance as is afforded by Or Organization this policy, I lowever, the person or organization is an insured only: if and then only to the extent the person or organization is described in the Schedule; to the extent such contract or agreement requires the person or organization to be afforded status as air insured; for activities that did not occur, in whole or in part, before the execution of the contract or agreement; and with respect to darnalges, loss, cost or expense for injury or darnage to which this insurance applies No person or organization is an insured under this Provision: that is more specifically identified under any other provision of the Who Is Air Insured section (regardless of zany liniitaiion applicable thereto). with respect to any assumption of liability (of another person or organization) by them in a contract or agreenient. This lirnhation does not apply to the liability for (kinnaves, loss, cost or expense for injury or darnage, to which this insurance applies, that the person or organization would have in the absence of'such contract or agreement. Liability Insurance Additional InAwwfA, , 9" organization continued I Pr r or .............. j'7,� e,v 5 - 0 7) Endorsen,)ent Page I REVEWED BYEUI` RC E HEREDIA Liability Endorsement (cc) n firr u f:,, d) Under Conditiom, t tie RAWwkg prow A on 0 Ad A to coedit on WWI a mom n ce, mommonogimm Other Insurance — f C you ant obhga wd, pmmant to a -Am" Or agul—W to plovido the pemn or organdmiurr Primary, Noncontributool Shu— i" to MUM "ith pNmHy hurum"a, such " N MAM,Q, &W in ,h ,o Msumnce — GUAM Is Own— n pnmg and we M mq suk coati whon p", ms—c avadhic M smh pesm Person Or Organizatiori ot- org'anizittitan , Schedule P,,�,fson� of orgarliziniuns tat you are obhgavd, pummn"o a such ",Is i,� affordu'd by thug policy. All colici ati(j a:cmditiuns r,,,rnain kifhodzed Repre,,.;PnCalmle Liability fnsuljnce Adcfitionai At pye, u7 '.'i .... ....... pap, REWEWED BY EUMCE DA MG.4 OF ...... .... Conditions (continued) Transfer Or Waiver Of We will waive the right of recovery we would otherwise have had against another 17ereyort or Rights Of Recovery organization, for loss to which this insurance applies, provided the insured has waived their rights Against Others of recovery against such person or oi-anizatiou in a Gontra:t or agreement that is executed before such lass. To tile, extent that the iunsured's rights to recover all or part of an.y payment made under this insurance have not been waived, those rights are trarlSferred to us. The insured must do nothing after loss to impair thein, At our request, the insured will bring suit or transfer those rights to us and help us entorce there. This condition does not apply to medical expenses, Liability Insurance: u ._..._._..�._...._.... (Per-C'1) ntrxc't ..... Page 24 of;32 ftii:lBlC_Wu. D BY3 :.._ .t PJNIC _.. _ AC<:>R Qr CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 12/29/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the pollcy(les) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER JLT Specialty USA Y - 135 Main Street Suite 1600 San Francisco, CA 94105 CONTACT NAME; Darya Kavalenka PHONE FAX -(A/C. o E 415 805-8857 , No): E-MAIL ADDRESS: Darya,Kavalenka ltus.com INSURERS AFFORDING COVERAGE NAICH www.jltre.com California License: OH01656 iNsuRERA: AXA Insurance Company 33022 INSURED sch TraffiCCom Holding II US Corp. Kapp1 INSURERS: Great Northern Insurance Company 20303 INsuRERc: Chubb Indemnity Insurance Company 12777 820Greensboro Drive Suite 1002 McLean VA 22102 INSURERD: INSURERE: INSURER F : COVERAGES CERTIFICATE NUMBER: Sc1RFion Fd REVISION NI IMRFR• THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT,. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL INSO SUER' WVD POLICY NUMBER POLICY EFF POLICY EXP (MMIDDNYYYI LIMITS A ,/ COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ❑✓ OCCUR PCS003157(17) 11/30/2017 7/1/2018 EACH OCCURRENCE $1000000 PREMISES Ea oculrrence $1 000 000 MED EXP (Any one person) $ 10 000 PERSONAL & ADV INJURY $1 000 000 AGGREGATE LIMITAPPLIES PER: POLICY Z jEO- El LOC GENERAL AGGREGATE $2,000,000 GEN'L PRODUCTS - COMP/OPAGG $2000000 ✓ OTHER: EBL Deductible: $1,000 Em to ee Benefits E&O $1 000 000 B AUTOMOBILE r LIABILITY ANYAUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY (17)73565101 11/30/2017 7/1/2018 Eo eBIINdE�DISINGLE LIMIT $ 1 000 000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTYDAMAGE Par acelde l $ $ A �/ UMBRELLA LIAO ,/ OCCUR X8003158(17) 11/30/2017 1/1/2018 EACH OCCURRENCE $5000000 EXCESS LIAR CLAIMS -MADE I AGGREGATE $ 6 000,000 DED I /I RETENTIONS 10,000 $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑N (Mandatory In NH) OF OPERATIONS below It yea, describe DESCRIPTION OF O NIA (17)71751328 11/30/2017 7/1/2018 _ STATUTE �RH E.L. EACH ACCIDENT $ 1 0DQ 000 E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $1 000 000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) City of Santa Ana, PWA - Transportation & Traffic Engineering Department are are Included as additional Insured (except for Workers Compensation) where required by written contract. Waiver of Subrogation Is applicable In favor of City of Santa Ana, PWA - Transportation & Traffic Engineering Department on the General Liability, Auto Liability, Umbrella Liability, and Workers Compensation where required by written contract. Additional Named Insured(s): Kapsch TrafficCom Transportation NA, Inc. REVIEWED BY: EUNICE HEREDIA (PG I OF ) VMIYVLLLM City of Santa Ana SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Citn: Vinh t Nguyen, P.E. Sr. Civil Engineer THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 9 Y I 9 ACCORDANCE WITH THE POLICY PROVISIONS. PWA - Transportation & `traffic Engineering 20 Civic Center Plaza Santa Ana CA 92701 AUTHORIZED REPRESENTATIVE , / l,1,p•- I Matt Rush ��LV� ©1988-2015 ACORD CORPORATION. All rinhfs ra¢arvarl ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 39659054 1 17-18 - GL AU UMB WC I Darya Kavalenka 1 12/29/2017 11:56:22 AN. (PST) I Page 1 of 2 AGENCY CUSTOMER ID: LOC #: ACCO ® ADDITIONAL REMARKS SCHEDULE Page of AGENCY NAMED INSURED JLT Specialty USA Kapsch TrafflcCom Holding II US Corp. 8201 Greensboro Drive Suite 1002 POLICY NUMBER McLean VA 22102 PCS003157 17 CARRIER NAIC CODE AXA Insurance Company 33022 EFFECTIVE DATE:11/30/2017 - - ----• - I v ZuV0 At UKU UUKPUHA T ION. All rights reserved. The ACORD name and logo are registered marks of ACORD ATTACHMENT 39659054 1 17-10 - GL AD UMD WC I Darya Xavalenka 1 12/29/2017 11:56:22 AM (PST) I Page 2 of 2 REVIEWED BY: EUNICE HEREDIA (PGOF POLICY NUMBER: PCS003157(17) COMMERCIAL GENERAL LIABILITY CG 20 37 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Location And Description Of Completed Operations All as required by written contract or agreement. All as required by written contract or agreement. REVIEWED BY: EUNICE HEREDIA (PG OF y) Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property damage" caused, in whole or in part, by "your work" at the location designated and described in the Schedule of this endorsement performed for that additional insured and included in the "products -completed operations hazard". However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. CG 20 37 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1 POLICY NUMBER: PCS003157(17) COMMERCIAL GENERAL LIABILITY CG 20 01 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance Condition and supersedes any provision to the contrary: Primary And Noncontributory Insurance This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: (1) The additional insured is a Named Insured under such other insurance; and (2) You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured. REVIE-IIVE_; E` EUNICE HEREDIA (PGY OF C/ ) CG 20 01 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1 EVANSTON INSURANCE COMPANY CERTIFICATE NO.: 2018-21 CERTIFICATE OF INSURANCE SPECIAL EVENT LIABILITY PROGRAM PRODUCER PUBLIC ENTITY (ADDITIONAL INSURED) Alliant Insurance Services, Inc. in conjunction with City of Santa Ana Apex Insurance Services 20 Civic Center Plaza P. O. Box 6450 Santa Ana, CA 92701 Newport Beach, CA 92658 License No: OC 36861 NAMED INSURED (EVENT HOLDER): EVENT INFORMATION: Blanca Arceo TYPE: Zumba 2119 W 17th Street, Apt G-5 DATE(S): 01/03/18 — 12/31/18 Santa Ana, CA 92706 N- ao�1-o��i LOCATION: Jerome Center *Liquor Liability Yes ❑ No "Liquor Liability after 12 am ends before 2 am ❑ This is to certify that the insurance policy listed below has been issued to the above insured named (event holder) for the policy period indicated. The insurance described herein is subject to all the terms, exclusions and conditions of such policy(ies) unless amended as described in Special Conditions. INSURANCE CARRIER: Evanston Insurance Company MASTER POLICY NUMBER: SEP41026 MASTER POLICY DATES: EFFECTIVE: JANUARY 1, 2018 EXPIRATION: JANUARY 1, 2019 COMMERCIAL GENERAL LIABILITY OCCURRENCE FORM DEDUCTIBLE: NONE General Aggregate Limit $ 2,000,000 Products & Completed Operations 1,000,000 SPECIAL CONDITIONS: Personal & Advertising Injury 1,000,000 The following endorsements attached to Each Occurrence Limit 1,000,000 the Master Policy do not apply to this Damage To Premises Rented To You (Any One Premises) 100,000 Certificate OF Insurance: Medical Payments (Any One Person) 5,000 MEGL643 Liquor Liability (If purchased) 1,000,000 Optional Limits Purchased ❑ $1,000,000/$3,000,000 ❑ $2,000,000/$2,000,000 Damage To Property (If purchased) The limits of insurance apply separately to each event insured by this policy asif a separate policy of insurance has been issued for that event. OTHER ADDITIONAL INSUREDS Silvia Salgado CANCELLATION: Should the above described policy be cancelled before the expiration date thereof, notice wilt be delivered in accordance with the policy provisions. AUTHORIZED REPRESENTATIVE: DATE ISSUED: WORKERS' COMPENSATION DECLARATION I Blanca Arceo hereby affirm under penalty of perjury, the (Name/Title) following declaration: I certify on behalf of Blanca Arceo that during the term of my (Consultant/Company Name) contract for Recreatinn Caasspa services with the City of Santa Ana, I will not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section J700 of the Labor Code, I shall forthwith comply with those provisions and provide proof of workers' compensation coverage. DATE: 12/7n6 By: �JC°Ntt f t G�Ir.Q Name: Blanca Arceo Title: Recreation Class Instructor Telephone: 714 805-0592 WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. ed by'. S Pdr� sd��a tr pFtG a� CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Marsh Risk and Insurance Services CONTACT r�nME_ Marsh Risk and Insurance Services 345 California Street PHONE FAX Suite 1300 Wc. No, �xt}: 415-743-8000 _(ac, No);__ EMAIL San Francisco, CA 94104 ADDRESS,. www.marsh.com California License: OH01556 INSURED Kappsch TrafficCom Holding II US Corp. 8201 Greensboro Drive Suite 1002 McLean VA 22102 COVERAGES CFRTIFICATF Nt1MRFR- F9r4R7iQa INSURE Is AFFORDING COVERAGE NAIC Y INSURER A: AXA Insurance Company 33022 INSURER B : Travelers PfODerty Casualtv Co of Amer 25674 INSURER D. Charter Oak_ Fire Insurance Company 25615 INSURER E REVISION Nt1MRFR- THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE INSU ADnI: suB POLICY NUMBER POLICYFF MMIDDmYY LIMITS R A COMMERCIALGENERALLIABILITY PCS003157(19) 7/1/2019 7/1/2020 EACHOCCURRENCE $1,00a000 l CLAIMS -MADE �/ OCCUR _ _ }AMAGF rO RENTEV PI{EMISFS jf=aoccurlArtcu), $ t 00 QQO , MED EXP JNky Mu parson) $ 1 O,000 PERSONAL & ADV INJURY . s 1,000,000 ..! fl'L AGGREGATF LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PEA LOC { I..._l mioDUCTs-CQMPIgPAGG T .s2.000000 $,QQ QQQ gTHER: DedUctlblB B AUTOMOBILE LIABILITY 810-1 N626414 7/1/2019 7/1/2020 COMBINEDflISINGLE LIMIT $1_ Q00 000 BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS $ J BODILY INJURY (Per accident) PROPERTY DAMAGE HIRED NON -OWNED $ AUTOS ONLY .�, AUTOS ONLY $ A UMBRELLA LIAR �/ OCCUR XS003158(19) 7/1/2019 7/1/2020 EACH OCCURRENCE $5 QQQ Q�Q AGGREGATE EXCESS LIAR CLAIMS -MADE $ 5 000,000 DED ✓ RETENTION$ 10.000 $ WORKERS COMPENSATION UB-OL500865 7/1/2019 7/1/2020 f SPER OT TATUTE ER AND EMPLOYERS' LIABILITY YIN ANYPROPRIETOR/PARTNER/EXECUTIVE E,L, EACH ACCIDENT $ 1 00000O OFFICER/MEMBER EXCLUDED? nN N / A (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE §A.,000.000 If yes, describe under DESCRIPTION OF OPERATIONS below I E.L. DISEASE - POLICY LIMIT $ 1,000,000 C .Tech E&O- Professional Liability G25604635004 7/1/2019 7/1/2020 $2.000,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Contract Numbers: A-2016-057 and A-2016-080 City of Santa Ana, officers, agents, employees, and volunteers, PWA - Transportation & Traffic Engineering Department are included as additional insured (except for Workers Compensation) where required by written contract. Waiver of Subrogation is applicable in favor of City of Santa Ana, PWA Transportation & Traffic Engineering Department on the General Liability, Auto Liability, Umbrella Liability, and Workers Compensation where required by written contract.. COncellaffors clause is amended to 30 day except for 10 day notice of cancellation for non-payment of premium per policy provisions. This Insurance is primary/noncontributory on the General Liability policy for the additional insured when such liability accrues from an act or omisslon of the named insured on tho policy. L;tK I II-IUA I t HULUtK L.AIYLCLLA I IUIV City of Santa Ana Risk Management Division 20 Civic Center Plaza Santa Ana CA 92702 By RISK MANAGEMENT DIVISION lvSP 509 FRAN-� CINE R. VILLAREAL SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Matt Rush © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD S135I199 1 19-18 GL AU Uinb WC $2M Professional I Matt Hush 19/2S/2019 1:S'/:31 PM (CDT) I Page 1 of 2 AGENCY CUSTOMER ID: LOC #: .4�oRo® ADDITIONAL REMARKS SCHEDULE L � Page of AGENCY NAMED INSURED Marsh Risk and Insurance Services Kappsch TrafficCom Holding II US Corp. 8201 Greensboro Drive Suite 1002 POLICY NUMBER McLean VA 22102 G25604635004 CARRIER NAIC CODE ACE American Insurance CompanyCompAny 2i67 EFFECTIVE DATE:7/1/2019 ADDITION THIS ADDITIONAL REMARKS FORM IS A SCHEDULE FORM NUMBER: 25 FORM TITLE: Certificate HOLDER: City of Santa Ana Risk Management Division ADDRESS: 20 Civic Center Plaza Santa Ana CA 92702 Policies evidenced herein inclu( Kapsch TrafficCom Holding Corp. Kapsch TrafficCom Inc. Kapsch TrafficCom USA, Inc. Streetline, Inc. ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ATTACHMENT S1357199 119-1B GL AU Uinb WC $2M Professional I Matt Rush 1 9/25/2019 1:57:31 PM (CDT) I Page 2 of 2