|
a DATE (MM
<br />�d /DDIYYYY) A CERTIFICATE OF LIABILITY INSURANCE 1j27/2017
<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 not confer rights to the
<br />certificate holder in lieu of such endorsement(s).
<br />PRODUCER CONTACT Paul Broussard
<br />NAME:
<br />Risk, 6 Insurance Consultants, Inc PHONE
<br />,.Ext): (404) 459-5975 (AA,.N®): (ataa- -5976
<br />5416 Glenridge Drive E-MAILAlib
<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
<br />WHICH THIS
<br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED
<br />BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL
<br />THE TERMS,
<br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
<br />1NSR pDDL SWBR
<br />TYPE OF INSURANCE
<br />'.... LTR POLICY NUMBER
<br />POLICY EFE POLICY EXP
<br />IMWOOIYYYYI (Mmmoi ....LIMITS
<br />X COMMERCIAL GENERAL LIABILITY
<br />EACH OCCURRENCE $
<br />1,000,000
<br />''. A CLAIMS -MADE X :'.. OCCUR
<br />DAMAGE TORENTED _. _...
<br />PREMISES (Ea occurrence) $ _
<br />30O 000...
<br />'
<br />X ILKKS0000006679900
<br />_._
<br />1/1/2017 1/1/2018 MED EXP (Any one person) $
<br />1,000
<br />PERSONAL &.ADV INJURY $
<br />1,000,000
<br />GENT AGGREGATE LIMIT APPLIES PERK
<br />GENERAL AGGREGATE $
<br />2,000,000
<br />X POLICYLOC
<br />JECT
<br />PRODUCTS - COMPIOPAGG $
<br />2,000,000
<br />OTHER,
<br />Employee Benefits Liability $
<br />1,000,000
<br />AUTOMOBILE LIABILITY
<br />COMBINED SINGLE LIMIT $
<br />(Ea accadent)................
<br />1,000,000
<br />X._. ANY AUTO
<br />BODILY INJURY (Per person) $
<br />B ......
<br />. ALL OWNED SCHL UULEU
<br />AUTOS AUTOS 1LXKB0004006679000
<br />........
<br />1/1/2017 1,/1,/2018 BODILY INJURY (Per accident) $
<br />.........
<br />X NON -OWNED
<br />PROPERTY DAMAGE,
<br />*' Ffl1RIEI3 AUTOS
<br />._..... , AUTC:S
<br />(Per accident)...
<br />Uninsured Motorist $
<br />1,000,000
<br />X UMBRELLA LIAR X OCCUR
<br />EACH OCCURRENCE $
<br />5,000,000 1
<br />A EXCESS LIAB CLAIMS MADE
<br />AGGREGATE $
<br />5, 000, 000
<br />DIED X RETENTION$ 0 lLKXSOOC..O006678900
<br />1/1/2.017 1/1/2018 $
<br />WORKERS COMPENSATION
<br />X PER OTH_
<br />AND EMPLOYERS' LIABILITY Y f N
<br />_.... STATUTE ER ..._.......
<br />ANY PROPRIETORWARTNERIEXECUTIVE
<br />E.L EACH ACCIDENT $
<br />1,000,000
<br />... N f A
<br />OFFICERIMEMBER EXCLUDED? X
<br />C (Mandatory in Ni TWC3601036
<br />1/1/2017 1/1/2018 E.L.DISEASE EA EMPLOYEE$
<br />1,000,000
<br />If yes. describe under
<br />DESCRIPTION OF OPERATIONS below
<br />E.L. DISEASE: - POLICY LIMIT $
<br />1 000 000
<br />D Participant Accident AHH006104.
<br />1/1/201.7 '. 1/1/2018 Accident/Medical
<br />4.
<br />$25,000
<br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional. Remarks Schedule, may he attached if more spa I iced)
<br />City of Santa Ana is additional insured, with regards
<br />to General L✓yy✓iIna ty, as per itten contract.
<br />�Rd f P''J ;
<br />TinyTykes
<br />r 011
<br />Dates: Feb 15th -•- May 20th, 2017
<br />� �
<br />,��C,
<br />r �
<br />British Soccer Camp
<br />a
<br />Dates: July 16th - 22nd, 2017�(
<br />SCuevas@santa-ana.org
<br />City of Santa Ana
<br />ATTN: Silvia Cuevas
<br />726 S Center Street
<br />Santa. Ana, CA 92704
<br />L
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />THE EXPIRATIONDATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />ACCORDANCE WITH THE POLICY PROVISIONS,
<br />AUTHORIXEO REPRESENTATIVE
<br />Steve Ma.l:i na/BF;CFGY
<br />C71988-2014 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
<br />INSf125 cqn lAnt t
<br />
|