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<br />DATE
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<br />CERTIFICATE OF LIABILITY INSURANCE
<br />6/7/2022
<br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS cz!Bohjf!
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<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 INSURER(S), AUTHORIZED
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<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.
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<br />If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
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<br />this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
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<br />PRODUCER Contact Name:Todd Tyler
<br />Cossio Insurance Agency
<br />PhoneFax
<br />(864) 688-0121
<br />(A/C, No, Ext):(A/C, No):
<br />PO Box 5987
<br />Greenville, SC 29606
<br />tammy@cossioinsurance.com
<br />E-Mail:
<br />(864) 688-0121
<br />INSURER(S) AFFORDING COVERAGENAIC #
<br />Nationwide Mutual Insurance Company23787
<br /> INSURER A:
<br />INSURED
<br />Ultimate Entertainment LLC, Dba Ultimate Entertainment LLC, Dba Mega Outdoor Mega Outdoor MoviesMovies
<br /> INSURER B:Berkley Life & Health Insurance Company64890
<br />12104 Park Street
<br />Cerritos,CA90703
<br /> INSURER C:
<br /> INSURER D:
<br /> INSURER E:
<br />COVERAGESCERTIFICATE 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 CONTRACT OR 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 />INSRTYPE OF POLICYADDLSUBRPOLICY NUMBERPOLICY EFFPOLICY EXPLIMITS
<br />LTRINSRWVD (MM/DD/YY) (MM/DD/YY)
<br />General Agg (Other than Products-C$2,000,000$2,000,000
<br />COMMERCIAL GENERAL LIABILITYCOMMERCIAL GENERAL LIABILITY
<br />X
<br />Each Occurrence$,000,000,000,000
<br />CLAIMS MADEOCCUR
<br />X
<br />Products and Completed Operations $000,000
<br />_______________________________
<br />Personal and Advertising Injury$,000,000
<br />FWC00000318231008/27/20218/27/20218/27/20228/27/2022Legal Liability to Participants$,000,000
<br />A
<br />XX
<br />_______________________________
<br />Professional Liability (for Event Plann$,000,000
<br />GEN'L AGGREGATE LIMIT APPLIES PER
<br />Damages to Premises Rented to You$300,000
<br />POLICYPROJECTLOC
<br />X
<br />Participant Accident - Excess Medica$10,000
<br />OTHER:
<br />Deductible$0
<br />COMBINED SINGLE LIMIT
<br />AUTOMOBILE LIABILITY
<br />$
<br />(Ea accident)
<br />ANY AUTO
<br />$
<br />BODILY INJURY (Per Person)
<br />ALL OWNEDSCHEDULED
<br />AUTOSAUTOS
<br />$
<br />BODILY INJURY (Per accident)
<br />HIRED AUTOSNON-OWNED
<br />AUTOS
<br />PROPERTY DAMAGE
<br />$
<br />(Per accident)
<br />OCCUR
<br />UMBRELLA LIAB
<br />CLAIMS-MADE
<br />EXCESS LIAB
<br />DEDRETENTION $
<br />PEROTH-
<br />WORKERS COMPENSATION
<br />STATUTEER
<br />AND EMPLOYERS' LIABILITY
<br />ANY PROPRIETOR/PARTNER/EXECUTIVE
<br />Y/N
<br />OFFICER/MEMBER EXCLUDED?
<br />N/A
<br />(Mandatory in NH)
<br />If yes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />Total Benefit Maximum for all Accident M$25,000
<br />Class 1 Principal Sum$25,000
<br />Accident Medical
<br />PAI L0120107785028/27/20218/27/2022
<br />Benefit Maximum$500,000
<br />B
<br />Accident Medical Deductible$100
<br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
<br />Party Equipment Rentals Operations located at 737 S State College BLVD Unit 94 Fullerton, CA 92831. Certificate Holder is listed as additional insured per form CG2011 when
<br />required by written contract. 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.required
<br /> by written contract. 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 />Amusement devices on file with the company for special event(s) dated 6/8/2022 to 6/8/2022 located at 20 Civic Center Plaza, Santa Ana, CA 92701.Waiver of Subrogation
<br />included when required by written contract.
<br />CERTIFICATE HOLDER:CANCELLATION
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORESHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />City Of Santa Ana, Its Officers, Agents, And EmployeesCity Of Santa Ana, Its Officers, Agents, And Employees
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED INTHE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED INTHE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />20 Civic Center Plaza20 Civic Center Plaza
<br />ACCORDANCE WITH THE POLICY PROVISIONS.ACCORDANCE WITH THE POLICY PROVISIONS.
<br />Santa Ana, CA 92702Santa Ana, CA 92702
<br />AUTHORIZED REPRESENTATIVEAUTHORIZED REPRESENTATIVE
<br /> © 1988-2015 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
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