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Page I oft Certificate of Insurance <br />Special Events <br />Name Insured: <br />Terembang Subandhi <br />14862 Colletta Place <br />Westminster. CA 92683 <br />Named Additional Insured: <br />SANTA ANA CITY OF -INDEPENDENT CITIES <br />RISK MANAGEMENT (SPECIAL EVENT) <br />20 Civic Center Plaza M-28 <br />SANTA ANA, CA 9270I <br />Certificate Term 1/12/2020 toll/l/2020 Certificate # COSA19-0017 <br />Coverage CITY OF SANTA ANA Special Event Policy Company: U.S. Specialty Insurance Company <br />Commercial General Liability Per Master Policy# 19/7004011 <br />Master Policy Effective Date:l I/l/2019 to expiration <br />Limits $2,000,000 General Aggregate / $1,000,000 Each Occurrence / $1,000,000 Products & Completed operations / <br />$1,000,000 Personal & Advertising Injury/$300,000 Damage to Rented Premises/ Medical Payments Excluded <br />Deductibles <br />$50.00 Premium (Fully Earned) <br />$0.00 Taxes (Fully Earned) <br />$40.00 Certificate Fee (Fully Earned) <br />TRIA <br />$90.00 Total Amount <br />Terms & <br />Conditions 1. Premium and All fees are fully earned. No Cancellations Allowed. <br />2. Hazard Class: 1 <br />3. Event Location: Albert Salgado Community Center <br />4. Event Description: Badminton Classes <br />5. Total Attendance: 120 Vendors: None <br />6. Attachments: Limited Contractual Endt., Designated Premises, Classification Limitation Endt. <br />7. Event Date: 1/12/2020 to 11/I/2020; Coverage Dates Twice a Week until I I/I/2020 (84 days total) <br />8. NO LIQUOR LIABILITY COVERAGE PROVIDED. <br />9. NO COVERAGE FOR BODILY INJURY TO ATHLETIC PARTICIPANTS AS A RESULT OF THEIR <br />PARTICIPATION. <br />Department Parks & Recreation <br />Exclusions Assault & Battery; Total Pollution; Asbestos; Lead Contamination; Animals; Nuclear, Employment Related <br />Practices; Liquor Liability; Cross Suits; Independent Contractors; Communicable Disease; Subsidence; Non- <br />Owned/Hired Auto; New Entities; Unscheduled activities or Events; Athletic Participants; Fireworks and Explosives; <br />Punitive Damages; Professional Liability; Voluntary Labor (For a complete list of the forms, conditions and <br />exclusions of the policy, refer to Master Policy.) <br />The insurance afforded under the specified policy above is subject to all terns, conditions, and exclusions of such <br />policy. (A copy of the policy is available upon written request.) This coverage applies only to the contractor or event <br />noted above and does not extend to any other activities or work performed by the holder. <br />MERRIWETHER & WILLIAMS INSURANCE SERVICES, Inc. should be notified at once of any claim arising <br />from your operation. Call 1-800420-0555 and a claims representative will assist you in the reporting process. <br />Coverage is primary and not contributing with any insurance maintained by the above public entitiy. The limits of <br />insurance apply to each event. If more than one named insured for any one event it will not increase the total limits <br />of liability available for that event. <br />BY RI WMp & APPROVED N <br />N 1 4 ZOZ� Ingrid Merriwether, Presi ent / Merriwether & Williams Insurance Services, Inc. <br />...... ul'rLAA U I AMBERT <br />550 Montgomery St., Suite 550 San Francisco, CA 94111 800.420.0555 415.986.3999 fax 415.986.4421 License# 0001378 <br />www.imwis.com <br />