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^"" ^ BLUEMAN-02 GINBODEI <br />[7t/2312017 <br />IM MIDDrYYYY) <br />CERTIFICATE OF LIABILITY INSURANCE <br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATEHOLDER, THIS <br />CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES <br />BELOW. THIS CERTIFICATE OF INSURANCE DOE'S 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 have ADDITIONAL INSURED provisions or be endorsed. <br />If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on <br />this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). <br />PRODUCER License # DGI9762 CONTACT <br />NAME: <br />Momentous Insurance Brokerage Inc PHONE FAX <br />5990 Sepulveda Blvd., #550 (Arc, No, Exty (818) 933-2700 (AJC, No):(818) 933-2701 <br />Wan Nuys, CA 91411 E-MAIL <br />INSURER(S) AFFORDING COVERAGE NAIL /r <br />INSURERA:P'hiladelphia Indemnity Insurance Company 18058 <br />INSURED INSURERS: State, Compensation Insurance Fund -MAIN 35076 <br />Blueray Management LLC INSURER c:Sentinel Insurance Company 11000 <br />P.O. Box 12529 INSURER®; <br />Newport Beach, CA 92668 <br />INSURERF: <br />r`.nVPPAf"1'FC rcoraZ=urArc kttrka0CC,. <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 13E ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED eY 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' '..ArJDL6UeR <br />LTR TYPE. OF INSURANCE D POLICY NUMBER__JMM1Q12JYYYY1 <br />PCLICYEFF POLIGYEXP <br />IMMIODNYYYl LIMITS <br />A X COMMERCIAL GENERAL LIABILITY <br />EACH OCCURRENCE $ <br />2,000,000 <br />CLAtlMS•MAOE X OCCUR PHPKI608851 <br />03124/2017 ' 03124/2018 DAMAGE To <br />rnrel 5 <br />100,000 <br />MEp EXP (Any one person) $ <br />0 <br />PERSONAL & ADV INJURY :. $. <br />2,000,000 <br />GENT AGGREGATE LIMIT APPLIES PER: <br />GENERAL AGGREGATE $ <br />4,000,000 <br />POLICY jEET LOG <br />PRODUCTS -COMPtOPAGG 11 <br />4,000,000 <br />$ <br />A AUTOMOBILE LIABILITY '. <br />: COMBINED SINGLE LIMIT <br />1,000,000 <br />X ANY AUTO PHPK1608851 <br />(Ea accident) $ <br />0:112412017 0312412018 BODILY INJURY (Per pe=ri) 8 <br />OWNEAUTOS SCHEDULED <br />X. <br />. AUTOS ONLY AUTOS - <br />BODILYiNJURY(Peraccidenl) $. <br />HIR NpIV'VVNLD. <br />AUT SONLY AUTO <br />PROPERTY DAMAGE <br />ONLY <br />;.(PeraccudenN) <br />UMBRELLA.LIAB OCCUR <br />EACH OCCURRENCE $' <br />EXCESS LIAR CLAIMS -MADE.. <br />AGGREGATE $ <br />j DED RETENTION$ <br />$ <br />WORKERS COMPENSATION <br />X PER CTH- <br />AND EMPLOYERS' LIABILITY Y IN 9201107-16 <br />ECUTIVE <br />12/231201 0510112017 STATUTE ER <br />1,000,000 <br />;. NIA <br />OFFICER/MEM6 R EXCLNLIDSO? <br />E.L. EACH ACCIDENT $ <br />(MandatorpinNH) -. <br />E.L. DISEASE - EAEMPLOYEE $ <br />1,000,000 <br />EI yes, describe �T " <br />DESCRIPTION OF OPERATIONS below <br />- <br />E.L. DISEASE -POUOY LIMIT $ <br />1,000,000 <br />C 'Business Owners Poll 72SBAAR9861 <br />0311512017 03/1512018 BPP <br />50,000 <br />DESCRIPTION OF OPERATIONS I LOCATIONS t VEHICLES (ACORn 101, Additional Remarks Sclleduls, may be attached If more space is required) <br />Certificate holder is <br />named as additional insured per the attached endorsements. <br />Primary and non contributory endorsementatta <br />SHOULD ANY OF THE ABOVE DESC BED POLICIES BE CANCELLED BEFORE <br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Santa Ana Parks, Recreation $Community <br />Services Agency ACCORDANCE WITH THE POLICY PRDVISI4N9, <br />1',625 W. Civic Center <br />Santa Ana, CA 92701 AUTHORIZED REPRESENTATIVE <br />(P1988-2015 ACORD CORPORATION. All rights reserved. <br />The ACORD name and logo are registered marks of ACORD <br />