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ASR& CERTIFICATE OF LIABILITY INSURANCE D0ATE 6/25IDDIY2 06/25/2012 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(les) 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 JOdnne Manion NAME n_ —__- _ .....--.......... PHONE FAX . 425-454-3386 AIC No: 425-451-3716 P.O. Box 367 E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAICp Bellevue, WA 98009-0367 INSURERA: American States Insurance Company INSURED INSURER B: Christiansen Amusements, Inc. INSURER C INSURER O: P. O. Box 997 INSURER E: Escondido, CA 92033-0997 INSURER F: COVERAGES CERTIFICATE NUMBER: 27846909 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 rypE OF INSURANCE AOOL SUER POLICY NUMBER POLICY EFF POLICY EXP MMIDDIYYYY MMIDDIYYYY LIMITS j1/, /yA GENERAL LIABILITY ^-'`10�e r EACH OCCURRENCE $ AMA N COMMERCIAL GENERAL LIABILITY j PREMISES Ea occurrence $ �I CLAIMS -MADE a OCCUR MED EXP (Any one person) $ PERSONAL S ADVINJURY $ GENERAL AGGREGATE$ GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG i$ POLICY PRO- LOC $ A AUTOMOBILE LIABILITY 01CI5624861 04/01/1; Ea accident 1,000,000 BODILY INJURY (Per Person) $ X ANY AUTO - ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Perasitlenti ) $ X NON-OWNEO HIRED AUTOS X AUTOS PROPERTY $ DAMAGE Per ctident $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ AGGREGATE$ EXCESS LIAB CLAIMS -MADE DED RETENTION$Li-♦/-/�1�'�` I$ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN FFICERIMEIANY E ECUTIVE ER EXCLUDED? NIA // iACCIDENT$ t L / T DTH- I TORY LIMITS E.L. EACH ACC E.L. DISEASE - EA EMPLOYEE ,$ (Mandator, ) -- E. L. DISEASE -POLICY LIMIT i $ If yes, describe under DESCRIPTION OF OPERATIONS below - I-aUla �('c i i DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more apace 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. Policy form CA 7110 0307 provides blanket additional insured wording - copy attached. RE: Carnival at Madison Park Event Dates: August 27 - September 4, 2012 CERTIFICATE HOLDER CANCELLATION ACORD 25 (2010105) Jomanion 27846909 ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 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 Plaaa AUTHORIZED REPRESENTATIVE Santa Ana, CA 92701 j1/, /yA OSA ^-'`10�e r ACORD 25 (2010105) Jomanion 27846909 ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD