JENNIFER BACKHAUS DBA BACKHAUS DANCE (2)

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CERTIFICATE OF LIABILITY INSURANCE DATE ) DS/28/2022 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Automatic Data Processing Insurance Agency, Inc. Automatic Data Processing Insurance Agency, Inc. PNONE E 1-600-524-7024 ac No: EMAIL ADDRESS: INSURE S AFFORDING COVERAGE NAICB 1 Adp Boulevard INSURER A: SIRIUS AMERICA INSURANCE COMPANY 38776 Roseland NJ 07068 INSURED BACKHAUS DANCE INSURER B: INSURER C : INSURER D : 4365 JOHANNA AVE INSURER E: LAKEWOOD CA 90713 INSURERF: COVERAGES CERTIFICATE NUMBER: 2476103 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADOL INSO SUBR MO POLICY NUMBER POLICY EFF (MWDDNYYYI POLICY EXP fMWDDNYYYILIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR EACH OCCURRENCE $ PREMISES Ea occurrence $ MED EXP (Anyone person) $ PERSONAL& ADV INJURY $ GEWL AGGREGATE LIMIT APPLIES PER: POLICY JEC LOG OTHER: GENERAL AGGREGATE $ PRODUCTS -COMPIOPAGG $ $ AUTOMOBILE LIABILITY ANY AUTO OWNED ASCHEDULED AUTOS ONLY UTOS HIRED NON -OWNED AUTOSONLY AUTOS ONLY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Par person) $ H BODILY INJURY (Per accident ) $ pR PERTY DAMAGE Per aaident $ $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTIONS $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY ECUTIVE V� OFFICEWMEM ER EXCLUDED' (Mandatory In NH) K yes, descrbe under DESCRIPTION OF OPERATIONS below N/A N WCSO946O0 O9/D]/2D21 Dg/07/2D22 PER STATUTE ER EL. EACH ACCIDENT $ 1,000,000 E.L. DISEASE -EA EMPLOYEE $ 1,000,000 E.L. DISEASE -POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached If more space Is required) City of Santa Ana, Attn: Risk Management Division 20 Civic Center Plaza, 4th floor Santa Ana CA 92702 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORRED REPRESENTATIVE Rial ld.%eewl Dvaim REMawm6 Mraw®Br. :;: 76uP4=oe ©1988-2015 ACORD C( �R�k,Ma„aseae'r as:mlade ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD r