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Page l of Certificate o Insurance TracyTracy <br />acobnedby <br />TracyJacobs <br />s ecial Events Jacobs D .1 .250207'00'9 <br />p 16:13:63-07'00' <br />Name Insured: <br />Vyvyenne Luyen <br />4255 Campus Dr. Unit 6566 <br />Irvine, Ca 92616 <br />Named Additional Insured: <br />SANTA ANA CITY OF- INDEPENDENT CITIES <br />RISK MANAGEMENT (SPECIAL EVENT) <br />20 Civic Center Plaza M-28 <br />SANTA ANA, CA 92701 <br />Certificate Term 10/1/2022 to 10/1/2022 Certificate # COSA21-0057 <br />Coverage CITY OF SANTA ANA Special Event Policy Company: Houston Casualty Company <br />Commercial General Liability Per Master Policy# H21TU00001 <br />Master Policy Effective Date:1 l/l/2021 to expiration <br />Limits $2,000,000 General Aggregate / $1,000,000 Each Occurrence / $1,000,000 Products & Completed operations / <br />$1,000,000 Personal & Advertising Injury/$300,000 Damage to Rented Premises/ Medical Payments Excluded <br />Deductibles <br />$100.00 Premium (Fully Earned) <br />$3.25 Taxes (Fully Earned) <br />$40.00 Certificate Fee (Fully Earned; <br />TRIA <br />$143.25 Total Amount <br />Terms & 1. Premium and All fees are fully earned. No Cancellations Allowed. <br />Conditions 2 Hazard Class: 2 <br />3. Event Location: Rosim Park <br />4. Event Description: Translator for Mid -Autumn Festival <br />5. Total Attendance: 200 Vendors: None <br />6. Attachments: Limited Contractual Endt., Designated Premises, Classification Limitation Endt. <br />7. Event Date: 10/1/2022 to 10/1/2022 <br />8. NO LIQUOR LIABILITY COVERAGE PROVIDED. <br />9. THIS POLICY DOES NOT PROVIDE COVERAGE FOR BODILY INJURY TO PERFORMERS OR <br />PARTICIPANTS AS A RESULT OF THEIR PARTICIPATION. <br />Department Parks and Recreation <br />Exclusions Assault & Battery; Total Pollution; Asbestos; Lead Contamination; Animals; Nuclear; Employment Related <br />Practices; Liquor Liability; Cross Suits; Independent Contractors; Communicable Disease; Subsidence; Non- <br />Owned/Hired Auto; New Entities; Unscheduled activities or Events; Athletic Participants; Fireworks and Explosives; <br />Punitive Damages; Professional Liability; Voluntary Labor (For a complete list of the forms, conditions and <br />exclusions of the policy, refer to Master Policy.) <br />The insurance afforded under the specified policy above is subject to all terms, conditions, and exclusions of such <br />policy. (A copy of the policy is available upon written request.) This coverage applies only to the contractor or event <br />noted above and does not extend to any other activities or work performed by the holder. <br />MERRIWETHER & WILLIAMS INSURANCE SERVICES, Inc. should be notified at once of any claim arising <br />from your operation. Call 1-800-420-0555 and a claims representative will assist you in the reporting process. <br />Coverage is primary and not contributing with any insurance maintained by the above public cmitiy. The limits of <br />insurance apply to each event. If more than one named insured for any one event it will not increase the total limits <br />of liability available for that event. <br />44 Montgomery St., Ste. 940 San Francisco, CA 94104 800.420.0555 415.986.3999 fax 415.986.4421 <br />.. wemmugene¢unwun <br />��`RenevEDSfiMPRopvm Bgv: <br />Inm:L f V6tsui2 <br />® Rak blanagemen[Analyst <br />www.imwis.com <br />