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AC40R"� CERTIFICATE OF LIABILITY INSURANCE (MMIDDfYYY ATE DY) 01/11/2 13 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER 1-425-454-3386 Arthur J. Gallagher Risk Management Services, Inc. CONTACT Joanne Manion NAME: PHONE 425-454-3386 FAX No; 425-451-3716 E-MAIL ADDRESS: P.O. BOX 367 INSURERS AFFORDING COVERAGE NAIC# Bellevue, WA 98009-0367 INSURER A: American States Insurance Company INSURED INSURER B : INSURER C Christiansen Amusements, Inc. INSURERD: P. O. BOX 997 INSURERE: Escondido, CA 92033-0997 INSURER F : CnVFRAGFS CERTIFICATE NUMBER: 31531360 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER EFF MMIDCDY/YYYY XP MMIDDIYLICY YYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea or $ MED EXP (Any one person) $ CLAIMS -MADE E OCCUR PERSONAL 8 ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ $ POLICY PRO LOC A AUTOMOBILE LIABILITY O1CI5624861 1 COMBINED SINGLE LIMIT Ea accident $ 1,000,000 BODILY INJURY (Per person) $ X ANY AUTO BODILY INJURY (Per accident) $ ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED X HIRED AUTOS X AUTOS PROPER Oident DAMAGE a c $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED I I RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETORIPARTNEREXECUTNE r-- OFF ICER/MEMBER EXCLUDED? u N / A I WC STATU- OTH- T R i E.L. EACH ACCIDENT $ (Mandatory In NH) E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT 1 $ If Yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) The City of Santa Ana, its officers, employees, agents and representatives are included as additional insureds but only as respects the operation of the named insured per policy terms and conditions per form CA7110 0307. RE: Jerome Park Carnival Event Dates: March 4 - 13, 2013 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Santa Ana THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Robert Carroll 20 Civic Center Plaza AUTHORIZED REPRESENTATIVE Santa Ana, CA 92701 �lr'��l'G USA © 1988-2010 AC9flPCffl&V90ICASA1fF4htM ACORD 25 (2010/05) jomanion 31531360 The ACORD name and logo are registered marks of ACORD / ' L A E ICK Assistant City Attorney 0