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OP ID: JU -, CERTIFICATE OF LIABILITY INSURANCE DATE( 07/Mm30/2013o,2013 ) 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 Wraith, Scarlett &Randolph Ins. Sergi Inc OB48084 CONTACT PHONE FAX NAIC, No Ext: WC, No 622 Main Street Woodland, CA 95695 Craig Huft EMAIL ADDRESS: PRODUCER CHRIS23 CUSTOMER ID N: INSURERS) AFFORDING COVERAGE NAICR INSURED Christiansen Amusements, Inc INSURERA: State Compensation Insurance 35076 Southland Shows, Inc Stacy Brown P.O. Box 997 INSURER e ! INSURER C INSURER D: Escondido, CA 92033 INSURER E: MED EXP Any one person) $ INSURER F: CLAIMS -MADE 1:1 OCCUR COVERAGES CERTIFICATE NUMBER: 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. HER R TYPE OF INSURANCE NSRADD vn POLICY NUMBER MMI�DIVVYY MMIDDIYYYV LIMITS Santa Alla, CA 92701-4058 GENERAL LIABILITY IEACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITYEN— ! PREMISES(Ea occurrence $ MED EXP Any one person) $ CLAIMS -MADE 1:1 OCCUR PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMPIOP AGO S POLICY PRO LOC $ AUTOMOBILE LIABILITYU �y pq '' J?+tl' tLL. - COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO �p�t_ ing i BODILY INJURY (Per person) $ ALL OWNED AUTOS ,,. +'" BODILY INJURY (Per accident) $ SCHEDULED AUTOS HIREDAUTOS--""`�� dP` "' 1N)�t S '! - PROPERTY DAMAGE (PERACCIDENT) — $ NONAWNEDAUTOS `''It\I $ ag15�a�it UMBRELLA LIAR OCCUR EACH OCCURRENCE I $ AGGREGATE $ EXCESS LIAR CLAIMS -MADE DEDUCTIBLE 5 _ $ RETENTION $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY! YIN ANY PROP R I ETORIPARTN ER/EXECUTIVE OFFICERWEMBER EXCLUDED? (MandatoryinNH) NIA/ 90680352013. 08/01/2013 j 08/01/2014 WC STATU- 01 X TORY 1 T$ ER E,L EACH ACCIDENT E. L. DISEASE -EA EMPLOYEE $ 1,090,000 —— $ 1,000,000 If yes, describe under . DESCRIPTION OF OPERATIONS below EL.DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Evidence of Insurance related to all Christiansen Amusements events between B/1/13 — 8/1/14. CERTIFICATE HOLDER CANCFI I. ATION CITYSA3 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Santa Ana 20 Civic Center Plaza AUTHORIZED REPRESENTATIVE Santa Alla, CA 92701-4058 ACORD 25 (2009109) © 1988.2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD