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Tori Pierson 1191111, signed by In Pierson <br />Date: 2021.09.2910:19:A7 -OM' <br />A`� El CERTIFICATE OF LIABILITY INSURANCE <br />DA E(MMI20 iY" <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 INSURERS), AUTHORIZED <br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. <br />IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(tes) 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 end, rsement. A statement on <br />this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). <br />PRODUCER <br />K&K Insurance Group, Inc. <br />1712 Magnavox Way <br />Fort Wayne IN 46804 <br />CONTACT NAME: Mass Merchandising <br />PHONE 1-800-328-2377 1-260-459-5502 <br />INC.No Ext : A/C No <br />EMAIL info@eventinsurance-kk.com <br />ADDRESS: <br />PRODUCER <br />CUSTOMER to: <br />INSURERS AFFORDING COVERAGE <br />NAIC# <br />INSURED 2001370465 CP# 430 <br />Pat Hurley <br />14920 Minneola Cf. <br />Tustin, CA 92780 <br />A Member of the Sports, Leisure & Entertainment RPG <br />INSURER A: Nationwide Mutual Insurance Co m an <br />23787 <br />INSURER B: <br />INSURER C: <br />INSURER D: <br />INSURER E: <br />INSURER F: <br />COVERAGES CERTIFICATE NUMBER: 2000515288 REVISION NIIMRFR- <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 />INSR <br />LTR <br />TYPE OF INSURANCE <br />ADDL <br />INSR <br />BUSH <br />WVD <br />POLICY NUMBER <br />POLICY EFF <br />hVpD1YYY <br />POLICY SKIP <br />MWDDIY <br />LIMITS <br />A <br />X <br />COMMERCIAL GENERAL LIABILITY <br />X <br />6BRPG0000007507400 <br />09/01/21 <br />09/01/22 <br />EACH OCCURRENCE <br />$1,000,000 <br />CWMSMAOE X OCCUR <br />12:01 AM <br />12:01 AM <br />DAMAGE TORENTEO <br />PREMISES Ea Occurrence <br />$1,000,000 <br />MEDEXP(Anyoneperaon) <br />$5,000 <br />PERSONAL& ADV INJURY <br />$1,000,000 <br />GI AGGREGATE LIMIT APPLIES PER: <br />POLICY PROJECT LOC <br />GENERALAGGREGATE <br />$5,000,000 <br />PRODUCTS—COMP/OP AGG <br />$1,000,000 <br />OTHER: <br />PROFESSIONAL UABILRY <br />$1,000,000 <br />LEGAL LIAB TO PARTICIPANTS <br />$1,G00,000 <br />AUTOMOBILE <br />LIABILITY <br />COMBINED SINGLE L T(Ea <br />accident) <br />OWNED SCHEDULED <br />BODILY INJURY (Per person) <br />IANYAUTO <br />AUTOS ONLY AUTOS <br />BODILY INJURY (Per accident) <br />HIRED NON -OWNED <br />AUTOS ONLY AUTOS ONLY <br />PROPERTY DAMAGE <br />Per accident <br />X <br />Not provided while in Hawaii <br />UMBRELLA LIAB OCCUR <br />EACH OCCURRENCE <br />EXCESS LIAB CLAIMS -MADE <br />AGGREGATE <br />DED RETENTION <br />WORKERS COMPENSATION <br />AND EMPLOYERS' LIABILITY <br />N/A <br />PER STATUTE OTHER <br />ANY PROPRIETOR/PARTNER/ Y/N <br />EXECUTIVE OFFICEWMEMBER <br />EXCLUDED? (Mandatory in Nip <br />E.L. EACH ACCIDENT <br />E.L. DISEASE— EA EMPLOYEE <br />Ilyes,clownbeunder <br />DESCRIPTION OF OPERATIONS below <br />E.L DISEASE— POLICY LIMIT <br />MEDICAL PAYMENTS FOR PARTICIPANTS <br />PRIMARY MEDICAL <br />EXCESS MEDICAL <br />DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached it more space Is required) <br />Instructor of: Instrumental music <br />The certificate holder is added as an additional insured, but only for liability caused, in whole or in part, by the acts or omissions of the named insured. <br />CERTIFICATE HOLDER CANCELLATION <br />City of Santa Ana Risk Management Division <br />20 Civic Center Plaza, 4th Floor <br />Santa Ana, CA 92702 <br />Owner/Manager/Lessor of Premises <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE <br />EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH <br />THE POLICY PROVISIONS. <br />AUTHORIZED REPRESENTATIVE <br />01980.2015 ACORD CORPORATION. All rights reserved. <br />11 <br />Rit/MsIgowdDlAstm <br />8i�. Y``'.iTir; I�wEvh.Oi Amxoxtn BY: <br />1rL-' iau ;arx'xaerc <br />Coverage is only extended to U.S. events and activities. Rakrana9eamrOs;�Iwae <br />NOTICE TO TEXAS INSUREDS: The Insurer for the purchasing group may not be subject to all the insurance laws an( _ <br />ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD <br />