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A ., _ : _ Diaitallv sianed by
<br />ACORL7® CERTIFICATE OF LIABILITY INSUNANCE Angie Acevedo DATE(MM/DDlYYYY)
<br />�./ Date: 2022.08.02 07/28/2022
<br />p�
<br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONF L%P'OW:M6f3ECt7)4)0�ATE HOLDER. THIS
<br />CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE rOVERAGE 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 />5`- te" 0 State Farm Insurance
<br />Greg Davis, Agfent, ChFC, CLU, RICP, LTCP, CASL
<br />1500 E Katella Ave, Suite 6
<br />CONTACT Kim Unland
<br />NA E:
<br />A/c No Ext : 714 633 3020 arc No : 714-633-2572
<br />E-MAIL Kim@gregdavis.biz
<br />INSURER(S) AFFORDING COVERAGE
<br />NAIC #
<br />INSURER A : State Farm General Insurance Company
<br />25151
<br />Orange CA 92867
<br />)NSURED
<br />INSURER B: State Farm Mutual Automobile Insurance Company
<br />25178
<br />INSURER C :
<br />Sarah Johnston
<br />INSURERD:
<br />DBA Showtime Dance Inc
<br />INSURER E :
<br />796 N Hart St
<br />INSURER F :
<br />Orange CA 92867
<br />CnVFRAGFS CFRTIFICATF NI IMRFR• RFVISION NIIMRFR-
<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 />INSR
<br />LTR
<br />TYPE OF INSURANCE
<br />ADD
<br />INSD
<br />S B
<br />WVD
<br />POLICY NUMBER
<br />POLICY EFF
<br />MM/DD/YYYY
<br />POLICY EXP
<br />MM/DD/YYYY
<br />LIMITS
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />EACH OCCURRENCE
<br />$ 1,000,000
<br />CLAIMS -MADE X OCCUR
<br />DAMAGE TO RENTED
<br />PREMISES Ea occurrence
<br />$ 300,000
<br />MED EXP (Any one person)
<br />$ 5,000
<br />PERSONAL & ADV INJURY
<br />$ 1,000,000
<br />A
<br />Y
<br />Y
<br />92-CR-P647-1
<br />07/23/2022
<br />07/23/2023
<br />AGGREGATE LIMIT APPLIES PER:
<br />GENERAL AGGREGATE
<br />$ 2,000,000
<br />GEN'L
<br />XPRO
<br />POLICY JECT LOC
<br />PRODUCTS - COMP/OP AGG
<br />$ 2,000,000
<br />$
<br />OTHER:
<br />I
<br />AUTOMOBILE LIABILITY
<br />92-CR-P647-1
<br />07/23/2022
<br />07/23/2023
<br />COMIN
<br />Ea accidentSINGLE LIMIT
<br />$
<br />BODILY INJURY (Per person)
<br />$ 1,000,000
<br />X ANY AUTO
<br />B
<br />X OWNED SCHEDULED
<br />AUTOS ONLY /� AUTOS
<br />Y
<br />BODILY INJURY (Per accident)
<br />$ 1,000,000
<br />PROPER I Y DAMAGE
<br />Per accident
<br />$ 1,000,000
<br />X HIRED NON -OWNED
<br />AUTOS ONLY AUTOS ONLY
<br />UMBRELLA LAB
<br />OCCUR
<br />EACH OCCURRENCE
<br />$
<br />AGGREGATE
<br />$
<br />EXCESS LIAB
<br />CLAIMS -MADE
<br />DED RETENTION $
<br />$
<br />A
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY
<br />ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N
<br />OFFICER/MEMBER EXCLUDED? LY]
<br />N /A
<br />92-CR-P647-1
<br />07/23/2022
<br />07/23/2023
<br />X I PTAT�T_ ORH
<br />$
<br />E.L. EACH ACCIDENT
<br />$ 1,000,000
<br />E.L. DISEASE - EA EMPLOYEE
<br />$ 1,000,000
<br />(Mandatory in NH)
<br />If yes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />E.L. DISEASE - POLICY LIMIT
<br />$ 1,000,000
<br />Per Occurance or Claim
<br />1000000
<br />A
<br />Sexual Abuse or Molestation (SAM)
<br />Liability
<br />Y
<br />92-CR-P647-1
<br />07/23/2022
<br />07/23/2023
<br />DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
<br />Description: Dance Instruction Additional Location: 410 W 4th St, Suite A, Santa Ana, CA 92701
<br />Lessor' Showtime Dance Inc Owner: Simple Venture, LLC
<br />CERTIFICATE HOLDER CANCELLATION
<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 it
<br />ACORD 25 (2016103) The ACORD name and logo a registe
<br />CA71VE
<br />I RiekManagma&DMsian
<br />REVIEWED be APPROVED BY:
<br />r2015 ACORD
<br />of ACORD Risk Management Specialist
<br />
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