ACORN®
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).
CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DDIYYYY)
07/01/2024
PRODUCER
Marsh Risk & Insurance Services
17901 Von Karman Avenue, Suite 1100
(949) 399-5800; License #0437153
Irvine, CA 92614
Attn: [email protected]/F: 212-948-4323 CN115158923--01-24-25
INSURED
PlaceWorks, Inc
3 MacArthur Place, Suite 1100
Santa Ana, CA 92707
ICONTE:ACT
NAM
IPHONE
(A/C No. Extl:
IE-MDREAIL
ADSS:
I INSURER(S) AFFORDING COVERAGE
INSURER A : Crum & Forster Specialty Insurance Co
INSURER B : Travelers Property Casualty Co. of America
1 INSURER C : N/A
I INSURER D :
1 INSURER E :
I INSURER F :
COVERAGES CERTIFICATE NUMBER: LOS -002640527-04 REVISION NUMBER:
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 ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSR wvD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY)
A X COMMERCIAL GENERAL LIABILITY EPK148300 07/01/2024 07/01/2025 EACH OCCURRENCE
DAMAGE TO RENTED
PREMISES (Ea occurrence)
MED EXP (Any one person)
PERSONAL & ADV INJURY
GENERAL AGGREGATE
FAX
(A/C, No):
NAIC #
44520
25674
N/A
CLAIMS -MADE
X BI & PD Ded. $5,000
X
OCCUR
GEN'L AGGREGATE LIMIT APPLIES PER:
X
POLICY
PRO-
JECT
OTHER:
B AUTOMOBILE LIABILITY
X ANY AUTO
OWNED
AUTOS ONLY
HIRED
AUTOS ONLY
■
■
LOC
SCHEDULED
AUTOS
NON -OWNED
AUTOS ONLY
UMBRELLA LIAB
EXCESS LIAB
DED RETENTION $
B WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANYPROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBEREXCLUDED?
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
OCCUR
CLAIMS -MADE
A Errors & Omissions -Claims Made
Retro Dates: See 2nd Page
YIN
N
NIA
BA-1N96406A-24-43-G 07/01/2024 07/01/2025
UB -7K728676 -24-43-G
07/01/2024 07/01/2025
EPK148300 07/01/2024 07/01/2025
PRODUCTS - COMP/OP AGG
Contractors Pollution
COMBINED SINGLE LIMIT
(Ea accident)
BODILY INJURY (Per person)
BODILY INJURY (Per accident)
PROPERTY DAMAGE
(Per accident)
Comp/Coll Deductibles
EACH OCCURRENCE
AGGREGATE
PER OTH-
XSTAUTE ER
E.L. EACH ACCIDENT
E.L. DISEASE - EA EMPLOYEE
E.L. DISEASE - POLICY LIMIT
Each Claim/Aggregate
5,000,000
100,000
10,000
5,000,000
5,000,000
5,000,000
5,000,000
1,000,000
1,000
1,000,000
1,000,000
1,000,000
5,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Re: Liability arising out of activities performed by or on behalf of the Consultant pursuant to its contract with the City; products and completed operations of the Consultant; premises owned, occupied or used by the Consultant; automobiles owned, leased, hired, or borrowed by the Consultant.
The City of Placentia and its elected and appointed boards, officers, officials, agents, employees, and volunteers are included as additional insured where required by written contract with respect to General Liability and Auto Liability.
CERTIFICATE HOLDER CANCELLATION
City of Placentia
401 E. Chapman Ave
Placentia, CA 92870
ACORD 25 (2016/03)
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
7 & 1 etuneotee Se/laze-4
© 1988-2016 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
ACORO�
AGENCY
Marsh Risk & Insurance Services
POLICY NUMBER
CARRIER
AGENCY CUSTOMER ID: CN115158923
LOC #: Irvine
ADDITIONAL REMARKS SCHEDULE
NAIC CODE
NAMED INSURED
PlaceWorks, Inc
3 MacArthur Place, Suite 1100
Santa Ana, CA 92707
EFFECTIVE DATE:
ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance Errors & Omissions Retro Dates:
7/1/99 - Planning Center, Inc.
1/1/87 - Design Community & Engineering Inc.
Subject to policy terms, conditions, limitations and exclusions.
ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
Policy EPK-144434 Effective 7/1/2023 — 7/1/2024
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
SCHEDULE
Name of Additional Person(s) orOrganizatlon(s): Location And Description Of Completed Operations Where Required By Written Contract. Where Required By Written Contract.
Information required to complete this Schedule, if not shown above, will beshown in the Declarations.
A. Section 111 - Who Is An Insured within the Common
Provisions is amended to include as an 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".
EN0320-0211 Page 1 of 1
Policy EPK-144434 Effective 7/1/203-7/1/2024
CRU M & FORSTER
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLV.
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
CONTRACTORS POLLUTION LIABILITY COVERAGE PART
SCHEDULE
Name OfAddltlonal Insured Person(s) or Organlzatlon(s)
Slanket when specifically required in a written contract with the named insured.
SECTION III -WHO IS AN INSURED within the Common Provisions is amended to include as an additional insured the person(s) or organization(s) indicated in the Schedule shown above, but only with respect to liability caused, in whole or in part, by •your worku for that insured which is performed by you or by those acting on your behalf.
ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED.
EN0111.0211 Pagel ofl
Policy EPK-144434 Effective 7/1/203 — 7/1/2024
FAM
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
PRIMARY AND NON --CONTRIBUTORY ADDITIONAL
INSURED WITH WAIVER OF SUBROGATION
This endorsement modifies insurance provided under thefollowing:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
CONTRACTORS POLLUTION LIABILITY COVERAGE PART
ERRORS AND OMISSIONS LIABILITY COVERAGE PART
THIRD PARTY POLLUTION LIABILITY COVERAGE PART
SCHEDULE
Name of Additional Insured Personfsl or OraanIzatlonfs) Where Required byWritten Contract
A. SECTION III - WHO IS AN INSURED within the Common Provisions is amended to include as an additional insured the person(s) or organization(s) indicated in the Schedule shown above, but solely with respect to "claims" caused in whole or in part, by "your work• for that person or organization performed by you, or by those acting on your behalf.
This insurance shall be primary and non-contributory, but only in the event of a named Insured's sole negligence.
B. We waive any right of recovery we may have against the person(s) or organization(s) indicated 1n the Schedule shown above because of payments we make for "damages" arising out of your work- performed under a designated project or contract with that person(s) or organization(s).
C. This Endorsement does not reinstate or increase the Limits of Insurance applicable to any "claim" lo which the coverage afforded by this Endorsement applies.
ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED.
EN0118.0211 Page 1 of 1
Policy# BA1N96406A2343G - Effective 07/01/2023
+n
C=
392N9
COMMERCIAL AUTO
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
BUSINESS AUTO EXTENSION ENDORSEMENT
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
GENERAL DESCRIPTION OF COVERAGE - This endorsement broadens coverage. However, coverage for any injury, damage or medical expenses described in any of the provisions of this endorsement may be excluded or limited by another endorsement to the Coverage Part, and these coverage broadening provisions do not apply to the extent that coverage is excluded or limited by such an endorsement. The following listing is a general cover- age description only. Limitations and exclusions may apply to these coverages. Read all the provisions of this en- dorsement and the rest of your policy carefully to determine rights, duties, and what is and is not covered.
A. BROAD FORM NAMED INSURED
B. BLANKET ADDITIONAL INSURED
C. EMPLOYEE HIRED AUTO
D. EMPLOYEES AS INSURED
E. SUPPLEMENTARY PAYMENTS - INCREASED
LIMITS
F. HIRED AUTO - LIMITED WORLDWIDE COV-
ERAGE - INDEMNITY BASIS
G. WAIVER OF DEDUCTIBLE - GLASS
PROVISIONS
A, BROAD FORM NAMED INSURED
The following is added to Paragraph A.1., Who is
An Insured, of SECTION II - COVERED AUTOS
LIABILITY COVERAGE:
Any organization you newly acquire or form dur-
ing the policy period over which you maintain
50% or more ownership interest and that is not
separately insured for Business Auto Coverage.
Coverage under this provision is afforded only un-
til the 180th day after you acquire or form the or-
ganization or the end of the policy period, which-
ever is earlier.
B. BLANKET ADDITIONAL INSURED
The following is added to Paragraph c. in A.1.,
Who Is An Insured, of SECTION 11 - COVERED
AUTOS LIABILITY COVERAGE:
Any person or organization who is required under
a written contract or agreement between you and
that person or organization, that is signed and
executed by you before the "bodily injury" or
"property damage" occurs and that is in effect
during the policy period, to be named as an addi-
tional insured is an "insured" for Covered Autos
Liability Coverage, but only for damages to which
CA T3 53 0215
H.
I.
J.
K.
L.
M.
N.
HIRED AUTO PHYSICAL DAMAGE - LOSS OF
USE- INCREASED LIMIT
PHYSICAL DAMAGE - TRANSPORTATION
EXPENSES - INCREASED LIMIT
PERSONAL PROPERTY
AIRBAGS
NOTICE AND KNOWLEDGE OF ACCIDENT OR
LOSS
BLANKET WAIVER OF SUBROGATION
UNINTENTIONAL ERRORS OR OMISSIONS
this insurance applies and only to the extent that
person or organization qualifies as an "insured"
under the Who Is An Insured provision contained
in Section II.
C. EMPLOYEE HIRED AUTO
1. The following is added to Paragraph A.1.,
Who Is An Insured, of SECTION 11 - COV-
ERED AUTOS LIABILITY COVERAGE:
An "employee" of yours is an "insured" while
operating an "auto" hired or rented under a
contract or agreement in an "employee's"
name, with your permission, while performing
duties related to the conduct of your busi- ness.
2. The following replaces Paragraph b. in B.5.,
Other Insurance, of SECTION IV - BUSI-
NESS AUTO CONDITIONS:
b. For Hired Auto Physical Damage Cover-
age, the following are deemed to be cov.
ered "autos" you own:
(1) Any covered "auto" you lease, hire,
rent or borrow; and
(2) Any covered "auto" hired or rented by
your "employee" under a contract in
an "employee's" name, with your
©2015 The Travelers Indemnity Company, All sights reserved. Page 1 of 4 Includes copyrighted material of Insurance Services OI11ce, Inc. with Its permisslon.
Policy# BA1 N96406A2343G - Effective 07/01/2023
perrnission, while performing duties
related to the conduct of your busi-
ness.
However, any "auto" that is leased, hired,
rented or borrowed with a driver is not a
covered "auto".
D. EMPLOYEES AS INSURED
The following is added to Paragraph A.1., Who Is
An Insured, of SECTION 11 - COVERED AUTOS
LIABILITY COVERAGE:
Any "employee" of yours is an "insured" while us-
ing a covered "auto" you don't own, hire or borrow
in your business or your personal affairs.
E. SUPPLEMENTARY PAYMENTS - INCREASED
LIMITS
1. The following replaces Paragraph A.2.a.(2),
of SECTION II - COVERED AUTOS LIABIL-
ITY COVERAGE:
(2) Up to $3,000 for cost of bail bonds (in-
cluding bonds for related traffic law viola-
tions) required because of an "accident"
we cover. We do not have to furnish these
bonds.
2. The following replaces Paragraph A.2.a.(4),
of SECTION II - COVERED AUTOS LIABIL-
ITY COVERAGE:
(4) All reasonable expenses incurred by the
"insured" at our request, including actual
loss of earnings up to $500 a day be- cause
of time off from work.
F. HIRED AUTO - LIMITED WORLDWIDE COV-
ERAGE - INDEMNITY BASIS
The following replaces Subparagraph (5) in Para-
graph 8.7., Policy Period, Coverage Territory,
of SECTION IV - BUSINESS AUTO CONDI-
TIONS:
(5) Anywhere in the world, except any country or
jurisdiction while any trade sanction, em- bargo,
or similar regulation imposed by the United
States of America applies to and pro- hibits the
transaction of business with or within such
country or jurisdiction, for Coy- ered Autos
Liability Coverage for any covered "auto" that
you lease, hire, rent or borrow without a driver
for a period of 30 days or less and Hlat is not
an "auto" you lease, hire, rent or borrow from
any of your "employees", partners (if you are a
partnership), members (if you are a limited
liability company) or members of their
households.
(a)
COMMERCIAL AUTO
With respect to any claim made or "suit"
brought outside the United States of
America, the territories and possessions
of the United States of America, Puerto
Rico and Canada:
(i)
You must arrange to defend the In-
sured" against, and investigate or set-
tle any such claim or "suit' and keep
us advised of all proceedings and ac-
tions.
(ii) Neither you nor any other involved
"insured" will make any settlement
without our consent.
(iii) We may, at our discretion, participate
in defending the "insured" against, or
in the settlement of, any claim or
"suit".
(iv) We will reimburse the "insured" for
sums that the "insured" legally must
pay as damages because of "bodily
injury" or "property damage" to which
this insurance applies, that the In-
sured" pays with our consent, but only
up to the limit described in Para-
graph C., Limits Of Insurance, of
SECTION II - COVERED AUTOS
LIABILITY COVERAGE.
(v) We will reimburse the "insured" for
the reasonable expenses incurred
with our consent for your investiga-
tion of such Bairns and your defense
of the "insured" against any such
"suit", but only up to and included
within the limit describecl in Para-
graph C., Limits Of Insurance, of
SECTION II - COVERED AUTOS
LIABILITY COVERAGE, and not in
addition to such limit. Our duty to make
such payments ends when we have
used up the applicable limit of
insurance in payments for damages,
settlements or defense expenses.
(b) This insurance is excess aver any valid
and collectible other insurance available
to the "insured" whether primary, excess,
contingent or on any other basis.
(c) This insurance is not a substitute for re-
quired or compulsory insurance in any
country outside the United States, its ter-
ritories and possessions, Puerto Rico and
Canada.
® 2015 The Travelers Indemnity Company. Al rights reserved. CA T3 53 02 15 Includes copyrighted material or Insurance Services Office, Jnc. with Its permission.
Policy# BA1N96406A2343G - Effective 07/01/2023
1 C=
111111111111
•* •
You agree to maintain all required or
compulsory insurance in any such coun- try
up to the minimum limits required by local
law. Your failure to comply with compulsory
insurance requirements will not invalidate
the coverage afforded by this policy, but we
will only be liable to the same extent we
would have been liable had you complied
with the compulsory in- surance
requirements.
(d) It is understood that we are not an admit-
ted or authorized insurer outside the
United States of America, its territories
and possessions, Puerto Rico and Can-
ada. We assume no responsibility for the
fumishing of certificates of insurance, or
for compliance in any way with the laws
of other countries relating to insurance.
G. WAIVER OF DEDUCTIBLE - GLASS
The following is added to Paragraph D., Deducti-
ble, of SECTION 111 - PHYSICAL DAMAGE
COVERAGE:
No deductible for a covered "auto" will apply to
glass damage if the glass is repaired rather than
replaced.
H. HIRED AUTO PHYSICAL DAMAGE - LOSS OF
USE - INCREASED LIMIT
The following replaces the last sentence of Para-
graph A.4.b., Loss Of Use Expenses, of SEC-
TION Ill - PHYSICAL DAMAGE COVERAGE:
However, the most we will pay for any expenses
for loss of use is $65 per day, to a maximum of
$750 for any one "accident".
I. PHYSICAL DAMAGE - TRANSPORTATION
EXPENSES - INCREASED LIMIT
The following replaces The first sentence in Para-
graph A.4.a., Transportation Expenses, of
SECTION I11 - PHYSICAL DAMAGE COVER-
AGE:
We will pay up to $50 per day to a maximum of
$1,500 for temporary transportation expense in-
curred by you because of the total theft of a cov-
ered "auto" of the private passenger type.
J. PERSONAL PROPERTY
The following is added to Paragraph A.4., Cover-
age Extensions, of SECTION T11 - PHYSICAL
DAMAGE COVERAGE:
Personal Property
We will pay up to $400 for 'Ioss to wearing ap-
parel and other personal property which is:
(1) Owned by an "insured"; and
COMMERCIAL AUTO
(2) In or on your covered 'auto'.
This coverage applies only in the event of a total
theft of your covered "auto".
No deductibles apply to this Personal Property
coverage.
K. AIRBAGS
The following is added to Paragraph 8.3., Exclu-
sions, of SECTION 111 - PHYSICAL DAMAGE
COVERAGE:
Exclusion 3.a. does not apply to 'loss" to one or
more airbags in a covered "auto" you own that in-
flate due to a cause other than a cause of 'loss" set
forth in Paragraphs A.1 .b. and A.1.c., but only:
a. If that "auto" is a covered "auto" for Compre-
hensive Coverage under this policy;
b. The airbags are not covered under any war-
ranty; and
c. The airbags were not intentionally inflated.
We will pay up to a maximum of $1,000 for any
one "loss".
L NOTICE AND KNOWLEDGE OF ACCIDENT OR
LOSS
The following is added to Paragraph A.2.a., of
SECTION IV- BUSINESS AUTO CONDITIONS:
Your duty to give us or our authorized representa-
tive prompt notice of the 'accident" or 'loss' ap-
plies only when the "accident" or 'loss" is known
to:
(a) You (if you are an individual);
(b) A partner (if you are a partnership);
(c) A member (if you are a limited liability com-
pany);
(d) An executive officer, director or insurance
manager (if you are a corporation or other or-
ganization); or
Any "employee" authorized by you to give no-
tice of the "accident" or "loss'.
M. BLANKET WAIVER OF SUBROGATION
The following replaces Paragraph A.5., Transfer Of
Rights Of Recovery Against Others To Us, of
SECTION IV - BUSINESS AUTO CONDI- TIONS:
5. Transfer Of Rights Of Recovery Against
Others To Us
We waive any right of recovery we may have
against any person or organization to the ex-
tent required of you by a written contract signed
and executed prior to any "accident"
or 'loss", provided that the "accident" or 'loss"
arises out of operations contemplated by
(e)
CA T3 53
0215
Policy# BA1N96406A2343G - Effective 07/01/2023
such contract. The waiver applies only to the
person or organization designated in such
contract.
N. UNINTENTIONAL ERRORS OR OMISSIONS
The following is added to Paragraph 8.2., Con-
cealment, Misrepresentation, Or Fraud, of
SECTION IV - BUSINESS AUTO CONDITIONS:
COMMERCIAL AUTO
The unintentional omission of, or unintentional
error in, any information given by you shall not
prejudice your rights under this insurance. How-
ever this provision does not affect our right to col-
lect additional premium or exercise our right of
cancellation or non -renewal.
Includes copyrighted material of Insurance Services Offlce, Inc. with Its permission.
CA T3 53 0215
TRAVELERS]
ONE TOWER SQUARE
HARTFORD CT 06183
;MAKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
ENDORSEMENT WC 99 03 76 ( A) - 001
POLICY UB -7K72867623 -43-G
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS
ENDORSEMENT -CAL IFORN
(BLANKET WAIVER)
We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule.
The additional premium for this endorsement shall be 2. oo % of the California workers' compensation pre- mium.
Schedule
Person or Organization
ANY PERSON OR ORGJfNJ. LATIO FOR
WHICH THE HOMED RAS AGREED
BY WRITTEN CONTRACT EXECU7'Iro
PRIOR TO LOSS TO FURNJ:SH TRIS
WAIVER.
Job Description
This endorsement changes the policy to which it is attached and Is effective on the date issued unless otherwise stated.
(Tho information below is required oily when this endorsement is issued subsequent to preparation of the policy.)
Endorsement Effective Policy No. Endorsement No.
Insured Premium
Insurance Company
DATE OF ISSUE:07/01/2023 ST ASSIGN: Pagel oft