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4CO & CERTIFICATE OF LIABILITY INSURANCE <br />DATE DIYYYV) <br />05/11/201 S <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 BELOW. <br />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 <br />CONTACT NAME: Mass Merchandising <br />K&K Insurance Group, Inc. - <br />1712 Magnavox Way <br />Fort Wayne IN 46804 N-? 018 111 <br />A10, No, Ext : 1-800-328-2317 FAX No 1-260-459-5502 <br />E-MAIL <br />DDRESS: info@eventinsurance-kk.com <br />APRODUCER <br />CUSTOMER ID: <br />INSURER(S) AFFORDING COVERAGE <br />NAIC# <br />INSURED 2000648858 CP# 107 <br />INSURER A: Nationwide Mutual Insurance Company <br />23787 <br />Kevin Christian NOonchesier <br />INSURER B: <br />DBA: NOTEWORTHY PUPPETS INC <br />INSURER C: <br />438 S LINCOLN PL <br />MONROVIA, CA 91016 <br />A Member of the Sports, Leisure & Entertainment RPG <br />INSURER D: <br />INSURER E- <br />INSURER F: <br />COVERAGES CERTIFICATE NUMBER: 2000361159 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 INDICATED. <br />NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE <br />ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF <br />SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br />INER <br />LTR <br />TYPE OF INSURANCE <br />ADOL <br />INSD <br />SUER <br />WVD <br />POLICY NUMBER <br />POLICY EFF <br />MWDD/YYY <br />POLICY EXP <br />MM/DDIYYVV <br />LIMITS <br />A <br />X <br />COMMERCIAL GENERAL LIABILITY <br />X <br />6BRPG0000006426200 <br />05/15/18 <br />05/15/19 <br />EACH OCCURRENCE <br />$2,000,000 <br />CIANMSMADE E] OCCUR <br />12:01 AM <br />12:01 AM <br />DAMAGE TO RENTED <br />PREMISES Ea Occurrence <br />$1,000,000 <br />MED EXP(Any one person) <br />$5,000 <br />PERSONAL &ADV INJURY <br />Excluded <br />GEN'L AGGREGATE LIMIT APPLIES PER: <br />GENERAL AGGREGATE <br />$5,000,000 <br />POLICY PROJECT LOC <br />PRODUCTS-COMP/OP AGO <br />$2,000,000 <br />PROFESSIONAL LIABILITY <br />OTHER: <br />LEGAL LAB TO PARTICIPANTS <br />$2,000,000 <br />AUTOMOBILE <br />LIABILITY <br />COMBINED SINGLE LIMIT a <br />accident <br />BODILY INJURY (Per person) <br />AUTO <br />IANY <br />OWNED SCHEDULED <br />AUTOS ONLY AUTOS <br />BODILY INJURY (Per accident) <br />HIRED NON -OWNED <br />AUTOS ONLY AUTOS ONLY <br />t {y <br />PROPERTY DAMAGE <br />Per accident <br />X <br />Not provided while In Hawaii <br />UMBRELLA OCCUR <br />LAB,�\ <br />EACH OCCURRENCE <br />EXCESS LAB CLAIMS MADE <br />DED RETENTION <br />J��'\,' <br />AGGREGATE <br />WORKERS COMPENSATION <br />ANY PROPRIETOWPARBNER/ ILITY YIN <br />EXECUTIVE OFFICER/MEMBER <br />EXCLUDED? (Mandatory In NH) <br />N/AAND <br />` <br />✓w\ <br />�. <br />rP` <br />7 <br />EACHA CID OTHER <br />E.L EACH ACCIDENT <br />E.A. DISEASE - EA EMPLOYEE <br />f yes, describe under <br />DESCRIPTION OF OPERATIONS below <br />-'+ <br />E.L. DISEASE- POLICY LIMIT <br />A <br />MEDICAL PAYMENTS FOR PARTICIPANTS <br />6BRPG0000006426200 <br />05/15/18 <br />12:01 AM <br />05/15/19 <br />12:01 AM <br />PRIMARY MEDICAL <br />$5,000 <br />EXCESS MEDICAL <br />DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be allached If more space Is required) <br />Performing as Puppeteer <br />City of Santa Ana, its officers, agents and employees are added as an additional insured, but only for liability caused, in whole or in part, by the acts or <br />omissions of the named insured <br />CERTIFICATE HOLDER CANCELLATION <br />City of Santa Ana <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE <br />Attn: Purchasing Department <br />EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH <br />20 Civic Center Plaza <br />THE POLICY PROVISIONS. <br />Santa Ana, CA 92701 <br />AUTHORIZED REPRESENTATIVE <br />/45-0 1 {'^r�G�-N <br />Owner/Manager/Lessor of Premises <br />©1988.2015 ACORD CORPORATION. All rights reserved. <br />Coverage is only extended to U.S. events and activities. <br />** NOTICE TO TEXAS INSUREDS: The Insurer for the purchasing group may not be subject to all the insurance laws and regulations of the State of Texas. <br />ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD <br />