|
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 -UK I HE FULICY YEKIUU
<br />INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
<br />CERTIFICATE MAYBE 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
<br />=+- CERTIFICATE OF LIABILITY INSURANCE 6/30/2017
<br />THIS CERTIFICATE IS ISSUED ASA 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
<br />Contact Name:
<br />Larry Cossio
<br />Cossio Insurance Agency
<br />Phone
<br />864-688-0121 Fax
<br />864-688-0138
<br />PO Box 5987
<br />(AIC, Na, Ezl):
<br />',(A/0, No):
<br />E -Mail:
<br />_
<br />tammy@cossicinsurance.com
<br />Greenville, SC 29606
<br />(864)688-0121
<br />INSURER(S) AFFORDING COVERAGE
<br />NAIC#
<br />INSURED
<br />INSURER A:
<br />NATIONWIDE MUTUAL INS CO
<br />23787
<br />All Star Event Rentals, Inc-
<br />---
<br />INSURER B:
<br />Berkley Life &Health Insurance Company
<br />64890
<br />23986 Aliso Creek Road Ste Al2#441
<br />_
<br />General Agg(Other than Products -C $5,000,000
<br />Laguna Niguel, CA 92677
<br />INSURER C:
<br />INSURER D.
<br />Each Occurrence $1,000,000
<br />❑
<br />A
<br />INSURER E:
<br />FWC00000279396-00
<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 -UK I HE FULICY YEKIUU
<br />INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
<br />CERTIFICATE MAYBE 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
<br />TYPE OF POLICY
<br />ADDL
<br />SUER
<br />_—.._—__.
<br />POLICY NUMBER POLICY EFF
<br />..................____..
<br />POLICY E%P
<br />LIMITS
<br />LTR
<br />INSR
<br />WVD
<br />(MM/DD/YY)
<br />(MM/DDIYY)
<br />X COMMERCIAL GENERAL LIABILITY
<br />Products B Completed Operations $1,000,000
<br />❑ ❑ CLAIMS MADE ❑X OCCUR
<br />Damage to Premises Rented to You $300,000
<br />F-1_
<br />_
<br />General Agg(Other than Products -C $5,000,000
<br />_ _ -
<br />Each Occurrence $1,000,000
<br />❑
<br />A
<br />X
<br />FWC00000279396-00
<br />1/25/2017
<br />125/2018
<br />Personal &Advertising Injury $1,000,000
<br />Legal Liability to Participants $1,000,000
<br />GENLAGGREGATE LIMITAPPLIES PER
<br />X POLICY ❑ PROJECT ❑LOC
<br />Professional Liability (for Event Plann $1,000,000
<br />Participant Accident - Excess Medica $10,000
<br />❑ OTHER.
<br />Deductible None
<br />AUTOMOBILE LIABILITY
<br />COMBINED SINGLE LIMIT
<br />$
<br />❑ ANY AUTO
<br />(Ea accident)
<br />BODILY INJURY (Per Person)
<br />$
<br />❑ AO❑ AUTOESULED
<br />AUTOS
<br />❑ HIREDAUTOSNON-OWNED
<br />❑
<br />BODILY INJURY (Per accident)
<br />$
<br />AUTOS
<br />❑ El
<br />DAMAGE
<br />(Peraccident)
<br />$
<br />❑ UMBRELLA LIAB ❑ OCCUR
<br />W
<br />`` GJ
<br />❑ EXCESS LIAR ❑ CLAIMS -MADE
<br />` -4� ..0
<br />'
<br />❑ DED ❑ RETENTIONS
<br />WORKERS COMPENSATION
<br />P
<br />PER
<br />(STATUTE
<br />OERH
<br />AND EMPLOYERS' LIABILITY
<br />5� G
<br />ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N
<br />OFFICER/MEMBER EXCLUDED?
<br />N/A
<br />nn
<br />l7C�
<br />C
<br />(Mandatory in NH) ❑
<br />It yes, describe under
<br />DESCRIPTION OF OPERATIONS be.
<br />Accident Medical Deductible $100
<br />Benefit Period 52 weeks
<br />B
<br />Accident Medical
<br />PAI L012R1825001
<br />1/25/2017
<br />1/25/2018
<br />Benefit Maximum $500,000
<br />Applies During per Covered Accident
<br />Applies To Death 8 Dismemberment Benefits only
<br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
<br />Party Equipment Rentals Operations located at 23986 Aliso Creek Rd Ste Al2#441 Laguna Niguel, CA 92677. Certificate Halder is listed as additional insured per forth CG2011.
<br />The cerfifrate 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 7/4/2017 to 7/4/2017 located at 3006 W. Centennial Road, Santa Ana, CA 92704.Covemge is excluded for
<br />Trackless Trains, Bungee Trampolines, Mechanical Bulls, Mechanical Surfboards, Carnival Games, Concession Machines, Tents, Tables, Chairs, Photabooths.
<br />CERTIFICATE HOLDER: CANCELLATION
<br />City of Santa Ana Parks, Recreation And Community Services Agency 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 />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />Santa Ana, CA 92702
<br />Q
<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
<br />
|