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Francine R. Digitally signed by Francine R. Villareal Villareal Date: 2021.09.09 12:48:50 -07'00' ' ` CERTIFICATE OF LIABILITY INSURANCE °A9/�/202'1 "' 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 endorsements . PRODUCER Automatic Data Processing Insurance Agen CONTACT Jennifer Backhaus N PHONE NC No Ext: 949 433-7338 FAX vc No: In Partnership with Pie Insurance Servic 1 ADP Boulevard Roseland, NJ 07068 Email I-,iMLd13ACKHAUSDANCE.0RG Address: INSURERS AFFORDING COVERAGE NAIC # 1850 INSURER& SIRIUS AMERICA INS CO 38776 INSURED INSURER B: BACKHAUS DANCE 4365 Johanna Ave INSURERC: Lakewood, CA 90713-3303 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 REQUIREM ENT, TERM OR CONDITION OF ANY CONTRACTOR 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. LIMITSSHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS. INS LTR TYPE OF INSURANCE ADDL INSR SUBIR WVD POLICY NUMBER POLICY EFF (MM/DD/YY) POUCY EXP (MM/DD/YY) UMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE ❑ OCCUR DAMAGE TO RENTED $ MED. EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PROJECT LOC ]POLICY PRODUCTS-COMP/OPAGG. $ OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE (Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXC ESS LIAR CLAIMS - MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N x PER STATUTE I OTH - ER A ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ N / A WC80946-00 9/7/2021 9/7/2022 E.L. EACH ACCIDENT $ 1, 330,033 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L. DISEASE - EACH EMPLOYEE $ 1, 330,033 E.L. DISEASE- POLICY LIMIT $ 1, 030,000 If yes, describe under DESCRIPTON OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) DANCE CLASSES CITY OF SANTA ANA RISK MANAGEMENT DIVISION 20 CIVIC CENTER PLZ SANTA ANA, CA 92VOl-4058 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 REPRESENTATNE _.---- ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD �oRaN RiskManagemerdDivisian REVIEWED & APPROVED BY: 3 z Risk Management Analyst