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Samantha Digitally signed by
<br />Samantha M. Lambert
<br />Date: 2
<br />CERTIFICATE OF LIABILITY INWftMydE54:3
<br />-07'00'
<br />DATE
<br />6/7/2022
<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
<br />BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING 1NSURER(S), AUTHORIZED
<br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
<br />-__.__-____.____.-.---.--__-.-.,.-___r-.-.,___ ..___-------_____ _ __ ------------...-___ _...__ -_ _------------. ____-..........-_ .___—_---------.,..,...-. _ .-_--_---
<br />IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the POIIcy(les) 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 Contact Name Todd Tyler -^ YY-Y-Y _-- - -_
<br />Cosslo Insurance Agency phone (864) 688-0121 Fax
<br />PO Box 5987 (AIC, No, Ext) (AIC, No_}; _
<br />.. .................
<br />Greenville, SC 29606 E-Mall: tammy@cossloinsurence.com
<br />(864) 6B"121------- -- --- ----- -- -- ----------....-------
<br />INSURER(S) AFFORDING COVERAGE NAIC #
<br />INSURED INSURER A: Nationwide Mutual Insurance Company 23787
<br />..,....... , . . .--.1... ... ... ... ... . -- .... --
<br />Creative Edge Amusemens Inc. INSURER B Berkley Life & Health Insurance Company 64890
<br />14210 Mulholland Dr.
<br />Los Angeles, CA 90077 INSURER C:
<br />-.--- --..........--------- --,.,.. _-_ --..._.__ ... ... ,..,..,..---
<br />INSURER D.
<br />--- - - -- ..... ,...... ..... -- ----.,.-....,.,..,... --- - .,., ....
<br />INSURER E: _
<br />COVERAGES CERTIFICATE NUMBER: 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
<br />INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
<br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
<br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
<br />INSR
<br />TYPE OF POLICY
<br />ADDL
<br />SUBR
<br />POLICY NUMBER
<br />POLICY EFF
<br />POLICY EXP ~
<br />LIMITS
<br />LTR
<br />INSR
<br />VVVD
<br />(MMIDDIYY)
<br />(MMIDDIYY)
<br />X COMMERCIAL GENERAL LIABILITY
<br />General Agg (Other than Products-C $2,000,000
<br />❑ ❑ CLAIMS MADE ❑X OCCUR
<br />❑
<br />Each Occurrence $2,000,000
<br />Products and Completed Operations $2,000,000
<br />Personal and Advertising Injury $2,000,000
<br />❑
<br />A
<br />X
<br />X
<br />FWC0000031476200
<br />8127/2021
<br />8/2712022
<br />Legal Liability to Participants $2,000,000
<br />Professional Liability (for Event Plann $2,000,000
<br />Damages to Premises Rented to You $300,000
<br />ParticipantAccident- ExcessMedica $10,000
<br />Deductible $0
<br />X POLICY PRROJOJ AGGREGATE APPLIES PER
<br />PROJECT �LOC
<br />OTHER:
<br />AUTOMOBILE LIABILITY
<br />ANYAUTO
<br />COMBINED SINGLE LIMIT
<br />(Ea accident)
<br />$
<br />BODILY INJURY (Per Perscn)
<br />$
<br />ALL OWNED SCHEDULED
<br />AUTOS ❑ AUTOS
<br />❑ HIRED AUTOS NON -OWNED
<br />❑ AUTOS
<br />BODILY INJURY (Per accident)
<br />$
<br />PROPERTY DAMAGE
<br />(Per accident)
<br />$
<br />❑ ❑
<br />❑ UMBRELLALIAB ❑ OCCUR
<br />—
<br />EXCESS LIAB ❑ CLAIMS -MADE
<br />DED ❑ RETENTION $___
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY
<br />W -
<br />PER
<br />STATUTE
<br />OTH-
<br />ER
<br />ANY PROPRIETORIPARTNERIEXECUTIVE YIN
<br />OFFICEWMEMBEREXCLUDED? ❑
<br />(Mandatory fn NH)
<br />NIA
<br />if yea, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />-
<br />Total Benefit Maximum for all Accident M - $25,000
<br />Class 1 Principal Sum $25,000
<br />B
<br />Accidart Medical
<br />PAI L012010778602
<br />8/27/2021
<br />8/27/2022
<br />Benefit Maximum $500,000
<br />Accident Medical Deductible $100
<br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more sp
<br />Party Equipment Rentals Operations located at 737 S State Collage BLVD Unit 94 Fullerton, CA 92831. Certificate Holder Is listed as addiVo
<br />reclulred by written contract. The certificate holder is added as an additional insured, but only for IlablRy caused, In whole or In part, by the ac
<br />Amusement devices on file with the company for special event(s) dated 618/2022 to 6/8/2022 located at 20 Civic Center Plaza, Santa Ana, Ci
<br />included when required by written contract,
<br />REVIEWED & APPRovED By. -
<br />S
<br />`�— Risk ManagementSupentisor
<br />CERTIFICATE HOLDER: CANCELLATION
<br />City Of Santa Ana, Its Officers, Agents, And Employees
<br />20 Civic Center Plaza
<br />Santa Ana, CA 92702
<br />SHOULD ANY OF THE ABOVE DESCRIBED POL VIUV ! iL yn,Yy LLGV �CrVRC
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />AUTHORIZED REPRESENTATIVE►-
<br />@ 1988-2015 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
<br />
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