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<br />CERTIFICATE OFLIABI�i�i PE"CE A__:_
<br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPC J 1.1 C 'FIf4Ijj I,�O E(R. TkjIS
<br />CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EX NO OR ALTER THE CO E';AG I �fl 7p
<br />BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE Axe,eve /! UING II:^IJRER(5), AUTHORIZED
<br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. VV vy 7.32� _ r r
<br />IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDrfIONAL 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 CONTACT Kim Unland
<br />StateFarm State Farm Insurance AICNNa Eat: 714-633-3020 ac No, : 714-633-2572
<br />iMAIL Greg Davis, Agent, ChFC, CLU, RICP, LTCP, CASL E, kim@gregdavis.biz
<br />° 1500 E Katella Ave, Suite 6
<br />INSURERS AFFORDING COVERAGE NAIC #
<br />Orange CA 92867 INSURER A: State Farm General Insurance Company 25151
<br />INSURED INSURER a : State Farm Mutual Automobile Insurance Comnanv 2517R
<br />Sarah Johnston
<br />DBA Showtime Dance Inc
<br />796 N Hart St
<br />Orange CA 92867 INSURER F:
<br />COVFRAGFS CFRTIFICATF Ml IMRFP- oFVrclnm All lmm=o•
<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 15 SUBJECT TO ALL THE TERMS,
<br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
<br />R'lZiR
<br />LTR
<br />TYPE OF INSURANCE
<br />ADD
<br />INSO
<br />SUB
<br />WVO
<br />POLICY NUMBER
<br />IMMmO1YYYYI
<br />IMMMDIYYYYILIMITS
<br />A
<br />COMMERCIAL GENERAL LIABILITY
<br />CLAIMS -MADE ❑X OCCUR
<br />Y
<br />Y
<br />I
<br />92-CR-P647-1
<br />1
<br />07/23/2021
<br />07/23/2022
<br />EACH OCCURRENCE
<br />$ 1,000,000
<br />EREMIETORENT
<br />I E Ea occur
<br />$ 300,000
<br />GEN'L
<br />MED EXP(Anyone person)
<br />$ 5,000
<br />PERSONAL a ADV INJURY
<br />$ 1,000,000
<br />AGGREGATE LIMIT APPLES PER:
<br />PRO-
<br />POLICY JECT
<br />OTHER:
<br />GENERAL AGGREGATE
<br />$ 2,000,000
<br />NLOC
<br />X
<br />PRODUCTS - COMPIOP AGO
<br />$ 2,000,000
<br />1
<br />$
<br />B
<br />AUTOMOBILE
<br />X
<br />X
<br />XHIRED
<br />LIABILITY
<br />ANY AUTO
<br />OWNED SCHEDULED
<br />AUTOS ONLY X AUTOS
<br />NON -OWNED
<br />AUTOS ONLY AUTOS ONLY
<br />Y
<br />92-CR-P647-1
<br />07/23/2021
<br />07/23/2022
<br />COMBINED
<br />Ma dam N
<br />$
<br />BODILY INJURY (Per person)
<br />$ 1,000,000
<br />BODILY INJURY (Per accident
<br />$ 1,000,000
<br />(Par accident)
<br />S 1,000,000
<br />UMBRELLA LIAB
<br />EXCESS LIAB
<br />OCCUR
<br />CLAIMS -MADE
<br />EACH OCCURRENCE
<br />$
<br />AGGREGATE
<br />$
<br />DEO RETENTION $
<br />$
<br />A
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY
<br />ANY PROPRIETORIPARTNERIEXECVTIVE YIN
<br />OFFICERIMEMBER EXCLUDED? ❑Y
<br />(Mandatory In NHl
<br />It yes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />NIA
<br />92-CR-P647-1
<br />07/23/2021
<br />07/23/2022
<br />PER OTH-
<br />S
<br />E.L. EACH ACCIDENT
<br />$ 1,000,000
<br />E.L. DISEASE - EA EMPLOYE
<br />$ 1,000,000
<br />E.L. DISEASE -POLICY LIMIT
<br />$ 1,000,000
<br />p'
<br />Sexual Abuse or Molestation (SAM)
<br />Liability
<br />Y
<br />92-CR-P647-1
<br />07I23/2021
<br />07/23/2022
<br />Per Occurance or Cla'un
<br />$1,000,000
<br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, A#dKlonal Remarks Schedule, may be attached If mom space Is required)
<br />Description: Dance Instruction Additional Location: 410 W 4th St, Suite A, Santa Ana, CA 92701
<br />Lessor: 5howUnne Dance, Inc owner: 5lmple Venture, LLC
<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 />City of Santa Ana Risk Management Division AUTHORIZED
<br />20 Civic Center Plaza
<br />Santa Ana CA 92702
<br />ACORD 25 (2016103) The ACORD name and logo
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<br />KMK manigaRea Ul11ki0A
<br />REVIEWED& APPROVEDBY:
<br />© -2015 ACORD
<br />Asfat&&W4n
<br />marks of ACORD
<br />Rhk Management Sproalist
<br />
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