Laserfiche WebLink
A� 1F CERTIFICATE OF LIABILITY INSURANCE <br />DATEtMMIDI)r Y ) <br />05128/2022 <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 <br />Automatic Data Processing Insurance Agency, Inc. <br />1 Adp Boulevard <br />Roseland NJ 07068 <br />CONTACT <br />NAME: Automatic <br />Data Processing Insurance Agency, Inc. <br />aHc N . 1-800-524-7024 uc N.), <br />E-MAIL <br />ADDRESS: <br />INSURERS AFFORDINGNAGE <br />NAIC6 <br />INSURER A; SIRIUS AMERICA INSURANCEECOMPANY <br />38776 <br />INSURED BACKHAUS DANCE <br />INSURER B: <br />INSURERC: <br />4365 JOHANNA AVE <br />INSURER D : <br />NSURERE: <br />LAKEWOOD CA 90713 <br />INSURER F: <br />COVERAGES UCK I H-HEA I t NUMBER' Z4/bl U3 rovtmm^u ur umvs. <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 CONTRACT OR OTHER DOCUMENT WITH RESPECT TO 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 />ILTR <br />TYPE OF INSURANCE <br />ADO <br />WVD <br />POLICY NUMBER <br />MMRIDY� <br />MMIDDYEXP <br />LIMITS <br />COMMERCIAL GENERAL LIABILITY <br />CLAIMS -MADE OCCUR <br />EACH OCCURRENCE <br />$ <br />NTEn— <br />PREMISES Ea occurrence <br />$ <br />MED UP (Any one person) <br />$ <br />PERSONAL B ADV INJURY <br />$ <br />GEN'L <br />AGGREGATE LIMIT APPLIES PER: <br />GENERAL AGGREGATE <br />$ <br />POLICY❑ PE0. LOC <br />PRODUCTS - COMP/OP AGO <br />$ <br />$ <br />OTHER: <br />AUTOMOBILE <br />LIABILITY <br />DNED ELIMIT <br />Ea accident <br />$ <br />ANY AUTO <br />BODILY INJURY (Per person) <br />$ <br />OWNED SCHEDULED <br />BODILY INJURY (Per accident) <br />$ <br />AUTOS ONLY AUTOS <br />HIRED NON -OWNED <br />AUTOS ONLY AUTOS ONLY <br />PROP RTYDAMA E <br />Per accident)$ <br />UMBRELLA LIAR <br />HOCCUR <br />EACH OCCURRENCE <br />$ <br />AGGREGATE <br />$ <br />EXCESS LIAB <br />CLAIMS -MADE <br />DED I <br />I RETENTION$ <br />$ <br />WORKERS COMPENSATION <br />AND EMPLOYERS' LIABILITY YINANY <br />STATUTE ERµ <br />E.L. EACH ACCIDENT <br />$ 110001000 <br />A <br />OFFICEWMEMBER EXCLUDED? <br />NIA <br />N <br />WC8094600 <br />09/07/2021 <br />09/07/2022 <br />( yes. dory In and <br />Dyes describe under <br />E.L.DISEASE- EA EMPLOYE <br />$ 1,000,000 <br />E.L. DISEASE -POLICY LIMIT <br />$ 1,000,000 <br />DESCRIPTION OF OPERATIONS below <br />DESCRIPTION OF OPERATIONS/ LOCATIONS I VEHICLES (ACORD 101. Addlthmal Remarks Schedule, may be attached if more space is required) <br />City of Santa Ana, Attn: Risk Management Division <br />20 Civic Center Plaza, 4th Floor <br />Santa Ana <br />CA 92702 <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 .i RM1ItMm$er�ml Ditidm <br />REbeaEc6AwRovm Bv: <br />k 1 %U Xrcworr <br />n 1988.2015 ACORn Or Raknw,ayeae,mm�Iwae <br />ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD N <br />