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74/4/2025 <br /> E(MM/DD/YYYY) <br /> A�" CERTIFICATE OF LIABILITY INSURANCE <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 INSURER(S), AUTHORIZED <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. <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 <br /> NAME: Certificate Department <br /> Olivier VanDyk Insurance Agency, Inc PHONE FAX <br /> 2780 44th St SW ..J No Ext: 616-454-0800 A/C,No):616-454-7100 <br /> E-MWyoming MI 49519 ADDRESS: certificates.sbu@ovdinsurance.com <br /> INSURER(S)AFFORDING COVERAGE NAIC# <br /> License#:0007645 INSURERA: Hudson Excess Insurance Company 14484 <br /> INSURED ULTIATT-01 INSURERB: National Union Fire Ins Co of <br /> Ultimate Entertainment LLC <br /> 12104 Park St INSURERC: <br /> Cerritos CA 90703 INSURERD: <br /> INSURER E: <br /> INSURER F: <br /> COVERAGES CERTIFICATE NUMBER:1364163789 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 /> INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS <br /> LTR INSD WVD POLICY NUMBER MM/DD MM/DD <br /> A X COMMERCIAL GENERAL LIABILITY Y Y HBD10057571 9/5/2024 9/5/2025 EACH OCCURRENCE $1,000,000 <br /> CLAIMS-MADE � OCCUR PREMISES DAMAGE TO <br /> PREMISES Ea occurrence) <br /> ccurrence $100,000 <br /> MED EXP(Any one person) $0 <br /> PERSONAL&ADV INJURY $1,000,000 <br /> GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 <br /> POLICY PRO- <br /> JECT LOC PRODUCTS-COMP/OP AGG $Included <br /> X <br /> OTHER: $ <br /> AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ <br /> Ea accident <br /> ANY AUTO BODILY INJURY(Per person) $ <br /> OWNED SCHEDULED BODILY INJURY(Per accident) $ <br /> AUTOS ONLY AUTOS <br /> HIRED NON-OWNED PROPERTY DAMAGE $ <br /> AUTOS ONLY AUTOS ONLY Per accident <br /> L $ <br /> UMBRELLALIAB OCCUR EACH OCCURRENCE $ <br /> EXCESS LAB CLAIMS-MADE AGGREGATE $ <br /> DED RETENTION$ $ <br /> WORKERS COMPENSATION PER OTH- <br /> AND EMPLOYERS'LIABILITY Y/N STATUTE ER <br /> ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ <br /> OFFICE R/M EMBER EXCLUDED? ❑ N/A <br /> (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ <br /> If yes,describe under <br /> DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ <br /> B Accident Medical Liability SRG 0009162922 9/4/2024 9/4/2025 Maximum Benefit $25,000 <br /> Ded $250 <br /> DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) <br /> City of Santa Ana, its City Council,officers,officials,employees,agents,and volunteers is additional insured to the extent that coverage is provided in the <br /> following endorsement. <br /> Tu Tran b T�aT,a�9ned <br /> Nguyen APPROVED <br /> Nguyen Date:2025.04.07 <br /> 09:0983-07'00' By Tu Tran Nguyen at 9:07 am,Apr 07,2025 <br /> CERTIFICATE HOLDER CANCELLATION <br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br /> THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br /> City Of Santa Ana, Attention: Parks, Recreation, and ACCORDANCE WITH THE POLICY PROVISIONS. <br /> Community Services Agency <br /> 20 Civic Center Plaza AUTHORIZED REPRESENTATIVE <br /> CA 92701, M-23 <br /> Santa Ana CA 92701l`, <br /> ©1988-2015 ACORD CORPORATION. All rights reserved. <br /> ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD <br />