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DARRWAG-01 BROSERTS <br />ACOR�� <br />CERTIFICATE OF LIABILITY INSURANCE <br />DATE IMMroDmYYi03130120'17 <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. Y <br />IMPORTANT; If the certificate holder Is an ADDITIONAL INSURED, the policy(€es) 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 endorsements . <br />PRODUCER - <br />A TgcT Brian Roberts <br />Blue L€on Brokers <br />4208198th St. SW Suite 208 <br />Lynnwood, WA 98036 <br />�a c°NrJ ext ; (425) 968-2238 wc, Na :(818) 827.33$0 <br />dLss; Brian@biuellonbrokers.com <br />INSURER(S) AFFORDING COVERAGE <br />NAIC H <br />• _ <br />SURER A: Mesa Underwriters Spec !al <br />INSURED <br />INSURERS <br />INSURER C : <br />Derrell Wagner dba Professional Entertainment <br />INSURER D : <br />P.O. Box 78593 <br />Seattle, WA 98179 <br />INSURER E <br />INSURER F <br />• <br />Cr]VFFlARPR CFRTIFICATF_ NUMRER- REVISION NUMBER: <br />THIS IS TO `CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD <br />INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENTWMTH RESPECT70 WHICH THIS <br />CER7IFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, <br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br />INER <br />TYPE OF INSURANCE <br />ADCL <br />SUER <br />POLICY NUMBER <br />POLICY EFF <br />POLICY EXP <br />LIMITS <br />A <br />X <br />COMMERCIAL GENERAL LIABILITY <br />OLAIMS-MADE [ OCCUR <br />X <br />MP0002007001476 <br />1210512016 <br />12/0612017 <br />EACH OCCURRENCE <br />$ 2,000,000 <br />DAEAGETORENTED <br />900000 <br />MEDBXP (Any one araan <br />$ 5,000 <br />PERSONAL&ADVINJURY <br />11000,000 <br />GEN'LAGGREGATELIMIT APPLIESPER: <br />X POLICY ❑ j LOC <br />OTHFR: <br />GENERAL AGGREGATE <br />$ 2,000,000 <br />PRODUCTS -COMPiOP GG <br />$ 2,000,005 <br />$ <br />AUTOMOSILELIABILITY <br />ANY AUTO <br />OWNED SCHEDAUTOS <br />AUTOSONLYAUTOSaS <br />ALTOS ONLY AaTI]SNLB <br />�� <br />�j�e� <br />�6a <br />_ <br />f <br />!- <br />I <br />✓ <br />E'n,'%.: INGLELIMIT <br />$ <br />BODILY INJURY Perperson) <br />5 <br />BODILY INJURY Peraccldenl <br />S ' <br />R <br />Pa�a cRt DAMAGEIII <br />S <br />JEX.Er,"5 <br />BRLLA LIAR <br />LIAa <br />OCCUR <br />CLAIMS -MADE <br />�® <br />° <br />1 <br />EACH CCCURRENCE <br />AGGREGATE <br />E <br />D RETENTION$ <br />S <br />WORKERS COMPENSATION <br />AND EMPLOYERS' LIABILITY YIN <br />AA�NppYICCPERROPRIE70RIPXCLU Eno ECUTIVE 7 <br />iMarldatory9n N)� <br />fyas deacrlbeunder <br />DESCRIPTION OF CPE ATIONS below <br />N! A <br />PER OTH- <br />E.L. EACH ACCIDENT <br />E.L. DISEASE - EA EMPLOYE <br />E.L. DISEASE- POLICY LIMIT <br />S <br />A <br />Abuse & Molestation <br />MP0002007001476 <br />12/0512016 <br />12f0512017 <br />100,000 <br />300,000 <br />DESCRIPTION OF OPERATIONS I LOCATIONS IVEHICLES (ACORD tin, Additional Remarks Schedule, may be attached if more apace Is required) <br />Certificate holder, its officers, agents, and employees are named as addAional Insured in regards to General Liability per attached CG 2015 11188. <br />10•day notice of cancellation for nonpayment. <br />City of Santa Ana <br />Attn: PRCSA <br />20 Civic Conter Plaza M-23 <br />Santa Ana, CA 92701 <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />AUTHORIZED REPRESENTATIVE <br />ACORD 25 (2016103) O 1988-2016 ACORD CORPORATION. All rights reserved. <br />The ACORQ name and logo are registered marks of ACORD <br />