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ACORD,. CERTIFICATE OF LIABILITY INSURANCE DATE(MWDDIYYYY)
<br />411ATIV
<br />THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLY AND OR
<br />NO RIGHTS UPON THE CERTIFICATE HOLDER TMIS CERTIFICATE DOES NOT ACT
<br />E POURS BETWEEN
<br />NEGATIVELY AMEND, EXTEND ZEDR PRTHECOVERAGEAFFORDED RYTHEP POLICIES BELOW.THISCERTIFICATE OF INSURANCE ODES NOT CONSTITUTER CONTRACT BETWEEN 7NE
<br />ISSUINGINSURERS,AUTHORREDr AND THE CERTIFICATE
<br />is 7n UUHXNEORSURED,the must be endorsed.
<br />IMPORTANT: If [rye on encate holder A an ADDITIONAL INSURED, the s not confer
<br />policies may fe ehe an andomsmanf. Asletement on this certificate does not conferdebts to the
<br />M SUBROGATION IS WAIVED, subject to the terms and conditions or the po isy, certain
<br />ceUlRcatp holder In lieu of such endorsements).
<br />PRODUCER
<br />NAME:
<br />AID, No. Ext: (913)327.0200 rUc, Nc; (913)327-0201
<br />Summit America Insurance Services
<br />7400 College Blvd., Suite 100
<br />ADDRESS:
<br />Overland Park, KS 66210
<br />Uc
<br />CUSTOMERIDd:
<br />INSURER(S)AFFORDINGCOVERAGE NAICN
<br />DAMAGE 10 RLN I ED
<br />PREMISES ae mm"nce $ 300,000
<br />INSURED
<br />INSURERA: Nationwide Mutual Insurance Company 28787
<br />Crosby Youth Athletic Association
<br />INSURER 8:
<br />CYAA
<br />533 Walnut Avenue, Unit 11
<br />INSURER C;
<br />INSURER D:
<br />Long Beach, CA 90802
<br />INSURER E:
<br />A Member of the Sports, Leisure & Entertainment RPG
<br />S R RF:
<br />COVERAGES CERTIFICATE NUMBER: 00017050 REVISION NUMBER:
<br />THIS IS TO CERTIFYE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSUREDNAMED ABOVE FOR THE L PERIO
<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 />JNSR
<br />LTR TYPE OF INSURANCE
<br />ADD
<br />INSR
<br />B
<br />WVO
<br />POLICY NUMBER
<br />MWDDIYYYY)
<br />POLICY EXP
<br />(MM/DD/YYM
<br />LIMITS
<br />,A, GENERAL LIABILITY
<br />X COMMERCIAL GENERAL LIABILITY
<br />CLAIMS -MADE FX OCCUR
<br />GEN'L AGGREGATE LIMIT APPLIES PER:
<br />POLICY 71 PROJECT F-1 LOG
<br />6B -RPG -53793
<br />12:01 AM
<br />4/5/2013
<br />12:01 AM
<br />4/5/2014
<br />EACH OCCURRENCE $ 1,000,000
<br />DAMAGE 10 RLN I ED
<br />PREMISES ae mm"nce $ 300,000
<br />MED Ext, (Any one person) $ 5,000
<br />PERSONAL SADV INJURY $ 1,000,000
<br />GENERAL AGGREGATE $ 5,000,000
<br />PRODUCTSCOMPIOPAGG $ 1,000,000
<br />PROFESSIONAL LIABILITY $ 1,000,OUO
<br />LEGAL LIAB TO PARTICIPANTS $ 1,000,000
<br />A
<br />AUTOMOBILE
<br />JXANY
<br />X
<br />X
<br />LIABILITY
<br />AUTO
<br />ALL OWNED AUTOS
<br />SCHEDULED AUTOS
<br />HIREDAUTOS
<br />NON -OWNED AUTOS
<br />Not provided while In Hewall
<br />66 -RPG -53793
<br />12:01 AM
<br />4/5/2013
<br />12:01 AM
<br />4/5/2014
<br />COMBINED SINGLE IMIT
<br />Ea Acei dent) 1 $ 1.000,000
<br />BODILY INJURY (Per person)
<br />BODILY INJURY (Per accident))
<br />PROPER
<br />Peraed sn'
<br />UMBRELLA LIAB OCCUR
<br />EXCESS LIAB CLAIMS -MADE
<br />DEDUCTIBLE
<br />RETENTION
<br />EACH OCCURRENCE
<br />AGGREGATE
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABLITY Y�/ N
<br />ANY PROPRIETORSHIP/PARTNER/
<br />EXECUTIVE OFFICEWM EMBER In NH)
<br />EXCLUDED?
<br />(Mandatory
<br />If Yes, UOzer lDa vndar
<br />DESCRIPTION 0n OPERATIONS below
<br />MIA
<br />TORY LIMITS OTHER
<br />E.L. EACH ACCIDENT
<br />E.L. DISEASE—EA EMPLEE
<br />OY
<br />E.L. DISEASE— POLICY LIMIT
<br />A
<br />MEDICAL PAYMENTS FOR PARTICIPANTS
<br />66 -RPG -53793
<br />12:01 AM
<br />4/5/2013
<br />12:01 AM
<br />4/5/2014
<br />PRIMARY MEDICAL NC
<br />EXCESS MEDICAL IS 25,000
<br />DESCRIPTION OF OPERATIONS? LOCATIONS I VEHICLES
<br />(Attach ACORD tei, Additional Remarks Schedule, if mono space [.required)
<br />Event Date(s): 6/16113-6122113 Sport: Basketball Location: 533 Walnut Avenue, Unit 11, Long Beach, CA 90802
<br />The City of Santa Ana, its officers, employees, agencts and representatives are added as additionally insured, but only Yrith respect to the liability, arising out of the opemilons
<br />of the insured named above.
<br />CERTIFICATE HOLDER CANCELLATION
<br />Coverage Is only extended to U.S. events and activities. "NOTICE TO TEXAS INSUREDS: The Insurer for the purchasing group may not be subject to all the
<br />Insurance laws and regulations ofthe State of Texas.
<br />ACORD 25 (2009109) 0'1988.2009 ACORD CORPORATION. All rights rosfrdyed,,,� T,jy
<br />The ACORD name and logo are registered marks of ACORD ry,��IDy�,{�,,.dd YY
<br />rig C
<br />A Sp ;STORGK F
<br />Assistant City Attorne`I
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
<br />Cit of Santa Ana
<br />City
<br />EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN ACCORDAN08 WITH THE
<br />POLICY PROVISIONS.
<br />20 Civic Center Plaza
<br />Santa Ana, CA 92701
<br />( c��p
<br />,
<br />Owner/Lessor of Premises
<br />AUTHORIZED REPRESENTATIVE
<br />Coverage Is only extended to U.S. events and activities. "NOTICE TO TEXAS INSUREDS: The Insurer for the purchasing group may not be subject to all the
<br />Insurance laws and regulations ofthe State of Texas.
<br />ACORD 25 (2009109) 0'1988.2009 ACORD CORPORATION. All rights rosfrdyed,,,� T,jy
<br />The ACORD name and logo are registered marks of ACORD ry,��IDy�,{�,,.dd YY
<br />rig C
<br />A Sp ;STORGK F
<br />Assistant City Attorne`I
<br />
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