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r1/20/2016
<br />ATE IMMIODIYYYY).
<br />C" CERTIFICATE OF LIABILITY INSURANCE
<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 be endorsed. If SUBROGATION IS WAIVED, subject to
<br />the terms and conditions of the Policy, certain policies may require an endorsement. A statement on this certificate does niot confer rights to the
<br />certificate holder In lieu of such endorsement(s).
<br />PRODUCER CONTACT Lyshon ,Tackson
<br />Risk & insurance Consultants, Inc PHO,N�o,Extj: (404)459-5975 {AC,Nnj:(404)a59-5976
<br />541E Glenridge Drive aE,OMAIILSs:.ljackson@riskinsuranceco.com
<br />INSURERIS) AFFORDING COVERAGE NANO tt
<br />.Atlanta GA 30342 INSURER Massachusetts Hay Ins 22306
<br />INSURED INSURER B Allmerica Financial Alliance Ins Co 10212
<br />Challenger Sports Corp INSURERc:Hanover Insurance Co 22292
<br />8263 Flint St INSURERD:Technology Insurance Company 42376
<br />INSURER,E :QBZ Ins Corp 39217
<br />Lenexa KS 66214 INSURER
<br />C0VFRAC;F9 C.FPTIFIrATF NI IMRFP-CL15123111050 I?FVICIY9N NI IMRPP-
<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 LTR TYPE OF INSURANCE ADOINSDL.SU ®. POLICY NUMBER _-. MMlOC YXYY' MMID6YY'Y
<br />... LIMITS
<br />X COMMERCIAL. GENERAL LIABILITY
<br />EACH OCCURRENCE ',.. $ 1,000,000
<br />A CLAIMS -MADE X OCCUR '.....
<br />.......... ..... .. ....
<br />DAMAGE TO RENTSrr 100,000
<br />PREMISE5(Ea.occurrence) $ _.....
<br />ZDA 9436702-04 1/1/2016 1./1/2017
<br />MED EXP (Any one person) $ 5,000
<br />PERSONAL & ADV INJURY $ 1,000,000' ..
<br />GFN'L AGGREGATE LIMIT APPLIES PER::
<br />... .......
<br />GENERAL AGGREGATE $ 2,000,000
<br />PRO-
<br />POLICY
<br />X2,000,000
<br />......., _.... JECT LOC
<br />PRODUCTS - COMP/OP AGO $ 2, 000 , 000...
<br />OTHIER
<br />Employee Benefits Liability $ 1, 000, 000
<br />AUTOMOBILE LIABILITY
<br />....._.
<br />COMBINED SINGLE LIMIT $ 1,000,000
<br />.LB. accident) ....._ _...
<br />H X... ANY AUTO _.
<br />BODILY INJURY {Per person) $ _.
<br />ALL OWNED SCHEDULED ADA9394043 1/1/2016 1/1/2017
<br />AUTOS AUTOS
<br />BODILYINJURY (Per accident) $
<br />NON -OWNED
<br />PER nl} DAMAGE $ _.
<br />PROPERTY
<br />HIRED AUTOS AUTOS,
<br />qP
<br />Uninsured motorist combined $ 1,000,000
<br />X.... UMBRELLA LIAR x OCCUR
<br />EACH OCCURRENCE $ 5,000,000
<br />C EXCESSLIAB .. CLAIMS -MADE.
<br />AGGREGATE $ 5,000,000
<br />DEC X RETENTION$ 0 UR.A9436692-04 1/1/2016 1/1/2017 :
<br />$
<br />WORKERS, COMPENSATION
<br />x PER OTH-
<br />AND EMPLOYERS' LIABILITY YIN
<br />STATUTE ER.
<br />ANY PROPRIETORYPARTNERIEXECUTIVE
<br />E.L. EACH ACCIDENT $ 1,000,000
<br />OFFICED ER EXCLUDED? N/A
<br />TWC3451515 1/1/2016 1/1/2017 (Mandatory in NH)
<br />Mandatory in
<br />E.L. DISEASE - EA EMPLOYEE $ 1,000,000
<br />It yes, describe under
<br />....
<br />DESCRIPTION OF OPERATIONS below
<br />E.L. DISEASE - POLICY LIMIT $ 1,000,000
<br />E, Participant Accident AHH006104 1./1/2016 1/1/2017
<br />Accident I Medical $25,000
<br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule,may be attached If more space Is required)
<br />Minikickers
<br />w
<br />Dates: February 15th - March 30th 2016
<br />(,:CK 111-I4;A I It HL)LIJ
<br />SCuevas@santa--ana.org
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />City of Santa Ana THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />ATTN: Silvia Cuevas ACCORDANCE WITH THE POLICY PROVISIONS.
<br />726 S Center Street
<br />Santa Ana, CA 92704 AUTHORIZED REPRESENTATIVE
<br />ISteve Mo1ir1a/IFCCKY -
<br />Q 1988-2014 ACORD CORPORATION. All rights reserved..
<br />ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
<br />INS025 0nt4ni i
<br />
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