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AC40 OR ® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) <br /> 04/04/2025 <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 CONTCT <br /> NAMEA Automatic Data Processing Insurance Agency, Inc. <br /> Automatic Data Processing Insurance Agency,Inc. IP H <br /> CONr o EXe: 1-800-524-7024 ac No <br /> E-MAIL <br /> ADDRESS: <br /> 1 Adp Boulevard INSURER(S)AFFORDING COVERAGE NAIC# <br /> Roseland NJ 07068 INSURER A: The Pie Insurance Company 21857 <br /> INSURED BACKHAUS DANCE INSURERB: <br /> INSURER C: <br /> 4365 Johanna Ave INSURER D: <br /> INSURER E: <br /> Lakewood CA 90713 INSURER F: <br /> COVERAGES CERTIFICATE NUMBER: 4231730 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 <br /> LTR INSD WVD POLICY NUMBER MM/DDIYYYY) (MMIDD[YYYYI LIMITS <br /> COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ <br /> CLAIMS-MADE OCCUR PREMISES Ea occurrence $ <br /> MED EXP(Any one person) $ <br /> PERSONAL&ADV INJURY $ <br /> GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ <br /> POLICY❑PRO- <br /> JECT ❑LOC PRODUCTS-COMP/OP AGG $ <br /> OTHER: $ <br /> AUTOMOBILE LIABILITY MBINED SIN LE L MI $ <br /> Ea accident <br /> ANY AUTO BODILY INJURY(Per person) $ <br /> OWNED SCHEDULED <br /> AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ <br /> HIRED NON-OWNED PROPERTY DAMAGE $ <br /> AUTOS ONLY AUTOS ONLY Per accident <br /> $ <br /> UMBRELLA LIAB H OCCUR EACH OCCURRENCE $ <br /> EXCESS LIAB CLAIMS-MADE AGGREGATE S <br /> ❑ED RETENTION$ S <br /> WORKERS COMPENSATION PER OT - <br /> AND EMPLOYERS'LIABILITY YIN <br /> STATUTE ER <br /> ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 <br /> A OFFICERIMEMBER EXCLUDED? ❑N NIA Y WCP11310148000 09/07/2024 09l07/2025 <br /> (Mandatory in NH) E.L.DISEASE-EA EMPLOYFF $ 1.000,000 <br /> If yes,describe under <br /> DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1.000,000 <br /> DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) <br /> This certificate has a blanket Waiver of Subrogation for the following state(s):CA <br /> APPROVED <br /> By Tu Tran Nguyen at 2:20 pm,Apr 08,2025 <br /> CERTIFICATE HOLDER CANCELLATION <br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br /> City of Santa Ana,Attn:Tram Le,Community Development THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br /> Agency,Arts&Culture ACCORDANCE WITH THE POLICY PROVISIONS. <br /> 20 Civic Center Plaza,M-25 <br /> AUTHORIZED REPRESENTATIVE <br /> Santa Ana CA 92701 <br /> ©1988-2015 ACORD CORPORATION. All rights reserved. <br /> ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD <br />