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MMID AC�® CERTIFICATE OF LIABILITY INSURANCE DATE/28/IYYzaz 11ze/ 3 3 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 CONTACT Edgewood Partners Insurance Center PHONE Lashuandra Collins FAX 10877 White Rock Rd (949) 994-8047 _ (A1C,No): E-MAIL Rancho Cordova CA 95670 ADDRESS: lashaundra.c011ins@e2icbrokers.com INSURE S AFFORDING COVERAGE NAIC# INSURER A:ADMIRAL INSURANCE COMPANY 24856 INSURED INSURER B:OHIO SECURITY INSURANCE COMPAN 24082 Stephen G. Muir Consulting Geologist & Geophysicist INSURERC:STATE COMPENSATION INSURANCE F 3-9076 19317 Windwood Drive INSURERD: Woodbridge CA 95258 INSURERE: INSURER F: COVERAGES SM CERTIFICATE NUMBER:Cert ID 21096 (3) 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 ADDLI W POLICY NUMBER MM�lLIOY EFF MOLICY>=XP T LIMITS LTR A x COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 E TO RENTED _. . CLAIMS-MADE X OCCUR Y I Y i FEI-ECC-16487-10 07/09/2023 07/09/2024 EMI rrence $ 50,000 MEDEXP(Any one ) S 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. GENERALAGGREGATE $ 2,000,000 PRO- POLICY L_1JECT 'I LOC j ( PRODUCTS-COMP/OPAGG S 2,000,000 OTHER. $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea acudenl $ 1,000,000 g ,�ANY AUTO Y I BAS2456619771 107/09/2023.07/09/2024 BODILY INJURY(Per personI $ OMED f j SCHEDULED •AUTOS ONLY X ;AUTOS I BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPER MA ffE R AUTOS ONLY X.'AUTOS ONLY Per ecpdenl $ I $ UMBRELLA LIAB j OCCUR EACH OCCURRENCE $ W EXCESS LIAB ^~_CLAIMS-MADE AGGREGATE $ DED RETENTIONS $ WORKERS COMPENSATION PER TH- C 'ANDEMPLOYERS'LIABILITY YIN 190319623 i05/01/202305/01/2024 X STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ N/A E.L.EACH ACCIDENT ;$ 11000,000 (Mandatory in NH) f j E.L.DISEASE-EAEMPLOYEEI $ 1,000,000 If ye5.describe under OESCR IPTIONOF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 A Professional Liability FEI-ECC-16487-10 07/09/2023�07/09/20241Each Occ. 5 1,000,000 I Aggregate $ 2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Re: Encroachment Permit Application, Project address: 521 N Cherokee Lane City of Lodi, its elected and appointed Boards, Commissions, Officers, Agents, Volunteers, and Employees are additional insured with respects to General Liability and Automobile Liability policies per the attached endorsements. General Liability policy is Primary and Non-Contributory per the attached endorsement. Waiver of Subrogation applies to General Liability policy per the attached endorsement. 30 days notice of cancellation applies to General Liability policy. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Lodi Public Works Department ACCORDANCE WITH THE POLICY PROVISIONS. 221 W Pine Street AUTHORIZED REPRESENTATIVE Lodi, CA 95241-1910 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Page 1 of 2