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CERTIFICATE OF LIABILITY INSURANCEs/2DATE
<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(Sh 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 />Cossio Insurance Agency
<br />PO Box 188
<br />Simpsonville, SC 29681
<br />(864)688-0121
<br />INSURED
<br />All Star Jumper Rentals, LLC
<br />117 North Standard Avenue, Suite A
<br />Santa Ana, CA 92701
<br />Name: Larry
<br />INSURER A:
<br />INSURER B:
<br />INSURER C:
<br />INSURER D
<br />INSURER E
<br />db4-bbb-VIZI
<br />JATIONWIDE MUTUAL INS CO
<br />3erkley Life & Health Insurance Company
<br />NAIC #
<br />eere/
<br />COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
<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 />—'i
<br />INSR TYPE OF POLICY _[AND
<br />LTR INSR, BURR POLICY NUMBER POLICY EFF POLICY EXP LIMITS
<br />MND (MM/ODIVV) (MM/OD/VV)
<br />X COMMERCIAL GENERAL LIABILITY
<br />Products & Completed Operations $1,000,000
<br />Ji CLAIMS MADE OCCUR
<br />Damage to Premises Rented to You $300,000
<br />r
<br />General Agg (Other than Products -C $5,000,000
<br />L
<br />Each Occurrence $1,000,000
<br />A [
<br />X.
<br />FWC00000273666-00
<br />3/23/2016 3/23/2017 Personal & Advertising Injury $1,000,000
<br />GEN'L AGGREGATE LIMIT APPLIES PER
<br />I Legal Liability to Participants $1,000,000
<br />X POLICY 1:1 PROJECT CLOG
<br />Professional Liability (for Event Plann $1,000,000
<br />FE OTHER
<br />' Deductible None
<br />'.
<br />Participant Accident - Excess Medical $10,000
<br />AUTOMOBILE LIABILITY
<br />COMBINED SINGLE LIMIT $
<br />ANY AUTO
<br />, F_ ANY
<br />''.
<br />accident) I
<br />_.
<br />LALL OWNED r --SCHEDULED
<br />BODI LY INJURY (Per Person) !$
<br />AUTOS a AUTOS
<br />E HIRED AUTOS NON -OWNED
<br />AUTOS
<br />I
<br />BODILY INJURY (Par accident) $
<br />i_
<br />L.
<br />^''\e�`'� PROP TY DAMAGE $
<br />1 ccldent)
<br />1
<br />C UMBRELLA LIAR C OCCUR
<br />EXCESS LIAR F CLAIMS-MADE
<br />DED 7 RETENTION $
<br />WORKERS COMPENSATION �'p �r�r PER 0TH-.
<br />AND EMPLOYERS' LIABILITY 'C'� STATUTE
<br />ANY PROPRIETOR/PARTNER/EXECUTIVE YIN
<br />OFFICERIMEMBER EXCLUDED? N/A
<br />(Mandatory in NH)
<br />If yes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />—. _ __
<br />' Loss Perictl 90 days after the Covered Accident
<br />Total Maximum for All Accident Medical $25,000
<br />B Accident Medical PAI L012RO371 001 ! 3/23/2016 3/23/2017 Accident Death & Dismemberment Behalf $25,000
<br />Applies During per Covered Accident
<br />Applies To Death & Dismemberment Benefits only
<br />_ — _._ 1L
<br />DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES (Attach ACORD 01, Additional Re_marks Schedule, if more space is required)
<br />Party Equipment Rentals Operations located at 117 North Standard Avenue, Ste A Santa Ana, CA 92701. Certificate Holder is listed as additional insured per form CG2026. The
<br />certificate holder is added as an additional insured, but only for liability caused, in whole or in part, by the acts or omissions of the named insured
<br />Amusement devices on file with the company for special event(s) dated throughout the policy period located at 20 Civic Center Plaza, Santa Ana, CA 92701. Coverage is excluded
<br />for Mechanical Bull
<br />CERTIFICATE HOLDER:
<br />CANCELLATION
<br />City Of Santa Ana, It's Officers, Employees, Agents And Representatives SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />20 Civic Center Plaza THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />Santa Ana, CA 92701 ACCORDANCE WITH THE POLICY PROVISIONS. ,� „
<br />AUTHORIZED REPRESENTATIVE
<br />© 1988-2014 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
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