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ATE <br />A� o CERTIFICATE OF LIABILITY INSURANCE 01120120161 <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(les) 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 not confer rights to the <br />certificate holder in lieu of such endorsement(s). <br />PRODUCER CONTACT L shon Jackson <br />NAME: Y <br />_ __— - __- <br />Risk &Insurance Consultants, Inc PHONE <br />-Le Exec (904) 959-5975 !A� W)e (a04)as9 s976 <br />.MAIL __ <br />$916 Glenridge Drive ADDRESS: l7ackson@riskinsuranceco. cost <br />INSURER(S) AFFORDING COVERAGE NAIC k <br />Atlanta GA 30342 INSURERA Massachusetts Bay Ins 22306 <br />INSURED INSURERS Allmerica Financial Alliance Ins Cc 10212 <br />Challenger Sports Corp INSURER C H_an_cv_e_r insurance Cc 22292 <br />8263 Flint St <br />INSURER D:Technology_Ynsurance Company '. 42376 <br />INSURERE.QBE Ins Corp. 39217 <br />Lenexa INS 66214 INSURER F: <br />rr)VFRAr:FS CFATICICATC NII Iru1QC0•CT,1 R 19'4111 nRD 0e1101n10 ♦nn,1000. <br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD <br />INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF <br />ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS <br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, <br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br />INSR ADDL'.. R, <br />LTR TYPE OF INSURANCE <br />-POL7CY EFP POLICYEXP `-------- ---_- <br />(MMiDDI""I IMMIDDIYYYY)LIMITS <br />X COMMERCIAL GENERAL LIABILITY <br />EACH OCCURRENCE ',$ 1,000, 000 <br />—I <br />A CLAIMSMAOE X OCCUR <br />;.._- __. <br />DAMAGET0 RERTEO <br />PREMISES (Re oocurrenceL ',$_ 100,000 <br />ZDA 9436702-04 <br />1/1/2016 1/1/2017 MED EXP(Any one person) ". $ 5,000 <br />PERSONAL&ADV INJURY $ 1,000,000 <br />GEN'L AGGREGATE LIMITAPPLIES PER: <br />-PRO- <br />GENERAL AGGREGATE ''�$ 2,000,000 <br />X <br />_POLICY JECT '. _. LOC <br />.- _ <br />I-NODUCTS- COMPIOP AGG $ 2,000,000 <br />OTHER'. -'. <br />Employee Benefits Llahlllly ! $ 1,000,000 <br />AUTOMOBILE LIABILITY <br />- , <br />B(EaPoINdED'SINGLE LIMIT I$ 1,000, 000 <br />B R ANY AUTO _ <br />BODILY INJURY (Per person) $ <br />ALL OPMED SCHEDULED <br />. AUTOS AUTOS ADA9394043 <br />' -�' ___ <br />1/1/2016 1/1/2017 aODILY INJUftV (Psr acodenq $ <br />_... <br />' NON-0WNF.D <br />PROPER -TV -DAMAGE <br />HIRED AUTOS AUTOS <br />&er acdtlem} <br />Uninsured motorist combined $ 1,000,000 <br />X UMBRELLA LIAR 'X I; OCCUR 1 '', <br />. EACH OCCURRENCE $ 5,000,000 <br />L, " EXCESS LIAR CLAIMS -MADE <br />AGGREGATE $ 5 000 000 <br />'OED '. X I RETENTION$ 0J UHA9436692-04 <br />'. 1/1/2016 1/1/2017 L$ <br />WORKERS COMPENSATION <br />R PER OTH. <br />ER <br />AND EMPLOYERS'LIABILITY YIN <br />—STATUTE_I__ <br />ANY PROPRIETORIPARTNERiEXECUTNE _ - <br />OFFICERIMEMBER EXCLUDED? '.NIA <br />EL EACH ACCIDENT $ 1 Q00 OQO <br />--- ...._._..___r_.� <br />D '.)Mandatary In NH) WC3451515 <br />1/1/2016 1/1/2017 EL DISEASE EA EMPLOYEE$ 1i 000000 <br />ll yyea, describe under <br />'DESCRIPTIONOFOPERATIONSbelox <br />E.L. DISEASE- POLICY LIMIT !$ 1 000, 000 <br />E Participant Accident AHH006104 <br />1/1/2016 1/1/2017 Aeoldenll Medieal $25,000 <br />DESCRIPTION OF OPERATIONS/ LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) <br />Minikickers <br />Vv�+ N <br />Dates: February 15th - March 30th 2016 <br />fJ4siv�e <br />[ <br />e\i <br />Cut <br />VGR I If14M I G IIVLUCR I.glNI.r LLM I IVIV <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 />Steve Molina/BECKY-.�!'--�----.I <br />0198&2014 ACORD CORPORATION. All riahts reserved. <br />ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD <br />INS02519nl4nrl <br />