|
Samantha M. D1911a11y signed by
<br />Samantha M. lambert
<br />i1 Lambert DaJ0: 2021.06.2s 15.12.10 SEASICE-01 IM RIC
<br />AFRO CERTIFICATE OF LIABILITY INSURANCE °ATIYYYY)
<br />8/24/2024/2021
<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.
<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 # 0757776 fi2WCT Brooke Barnett
<br />Encino, CA - GNW - HUB International Insurance Services Inc. PxoME PAX
<br />16030 Ventura Blvd. (ac, No, Ext: luc, No
<br />Suite 500 a7D,� : brooke.barnett@hubinternational.com
<br />Encino, CA 91436
<br />INSURED
<br />Seaside Ice, LLC
<br />501 Herondo St. Apt. 56
<br />Hermosa Beach, CA 90254
<br />COVERAGES CERTIFICATE NUMBER: RFVICInN MIIMRPa-
<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 DOCUMENTWITH RESPECTTO 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 />INSR
<br />LTR
<br />TYPE OF INSURANCE
<br />ADDL
<br />SUER
<br />POLICY NUMBER
<br />POLICY EFF
<br />DDYYYY1
<br />10126/2020
<br />POLICY EXP
<br />LIMITS
<br />A
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />CLAIMS -MADE X OCCUR
<br />X
<br />PK202000012079
<br />10126/2021
<br />EACH OCCURRENCE
<br />$ 1,000,000
<br />DAMAGE TO RENTED
<br />PREMISES nmca
<br />7000og
<br />MEDEXP An one eraon
<br />5,000
<br />PERSONALS ADV INJURY
<br />1,000,000
<br />GEN'LAGGREGATE
<br />X
<br />LIMIT APPLIES PER:
<br />POLICY j �T � LOC
<br />GENERAL AGGREGATE
<br />11 2,000,000
<br />PRODUCTS - COMP/OP AGO
<br />$ 2,000,000
<br />$
<br />OTHER:
<br />A
<br />AUTOMOBILE
<br />LIABILITY
<br />COMBINED SINGLE LIMIT
<br />1,000,000
<br />IxANYAUTO
<br />BODILY INJURY Perperson)
<br />$
<br />OWNED X SCHEDULED
<br />AUTOS ONLY AUTOS
<br />AU202000014259
<br />10/2612020
<br />10126/2021
<br />BODILY INJURY Per accident
<br />AUR OS ONLY X AIOIrNOS ONE
<br />P 1P.EFdZt AM1E
<br />$
<br />A
<br />X
<br />UMBRELLA LIAe
<br />X
<br />OCCUR
<br />EACH OCCURRENCE
<br />$ 5,000,000
<br />AGGREGATE
<br />$ 5,000,000
<br />EXCESS LIAB
<br />CLAIMS -MADE
<br />UM202000006174
<br />1012612020
<br />1012612021
<br />DEO I I RETENTION$
<br />A
<br />WORKERS COMP NATION
<br />AND WORKERS COMPENSATION
<br />ANY PROPRIETOWPARTNERUEXECUFIVE YIN
<br />ppFFIppEWEMBER EXCLUDED?
<br />(Mantlatory In NH)
<br />If yes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />NIA
<br />WC202000015566
<br />10/26/2020
<br />1012612021
<br />PER OTH-
<br />E ER
<br />E.L. EACH ACCIDENT
<br />1,000,000
<br />E.L. DISEASE -EA EMPLOYEE
<br />1,000,000
<br />E.L. DISEASE - POLICY LIMIT
<br />1,000,000
<br />A
<br />Inland Marine
<br />PK202000012079
<br />1012612020
<br />1012612021
<br />Misc. Equipment
<br />2,818,881
<br />A
<br />Misc. Equipment
<br />PK202000012079
<br />10126/2020
<br />1012612021
<br />Deductible
<br />2,500
<br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 10d. Additional Remarks Schedule, may be attached If more space is required)
<br />The City of Santa Ana, its officers, officials, employees, and volunteers are included as Additional Insured as respects to claims arising out of the operations
<br />of the Named Insured. This coverage Is primary.
<br />RE: 2021 Santa Ana Winter Village
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />City of Santa Ana THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />Risk Management Division ACCORDANCE WITH THE POLICY PROVISIONS.
<br />20 Civic Center Plaza
<br />Santa Ana, CA 92702 AUTHORIZED REPRESENTATIVE
<br />y �e 1thkMmM�rlvdDbidmL
<br />✓iw� � REVIEWEO&APPROVEDBr
<br />ACORD 25 (2016/03) ©1988-2015 ACORD C-"`�"'A
<br />The ACORD name and logo are registered marks of ACORD ® Ruk Management Supewlsor
<br />
|