JENNIFER BACKHAUS DBA BACKHAUS DANCE (3)

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ACOR& CERTIFICATE OF LIABILITY INSURANCE `/ DATE(MMIODIYYYY) 1 05/28/2022 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. AICNN 1-800-524-7024 NC No), EMAIL ADDRESS: INSURERS) AFFORDING COVERAGE NAIC4 1 Adp Boulevard INSURER A: SIRIUS AMERICA INSURANCE COMPANY 36776 Roseland NJ 07068 INSURED BACKHAUS DANCE INSURER e INSURER C : INSURER D : 4365 JOHANNA AVE INSURER E : LAKEWOOD CA 90713 INSURER F: 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 ADDLSUBR INSD MD POLICY NUMBER POLICY EFF MMIDDIYYYY POLICY EXP MMIDDIYYVY LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR EACH OCCURRENCE $ PREMISES Ea ocmmmme $ MED EXP(My one person) $ PERSONAL &ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY jEO F I LOC OTHER: GENERALAGGREGATE $ PRODUCTS - COMPIOP AGG $ $ AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Par person( $ BODILY INJURY (Par acci) tlent $ PROPERTY DAMAGE Per accident $ UMBRELLA LIAR EXCESS LIAR OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY OFFICERIMEM ER EXCLUDED?ECUTIVE YIN (Mandatory in NH) gym. deembe under DESCRIPTION OF OPERATIONS below NIA N WC8094600 09/07/2021 09/07/2022 OTH- 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 I VEHICLES (ACORD 101, Additional Remarks Schedule, may be 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. AUTHORIZED REPRESENTATIVE 4�,d„o Wale Mro�gewdDlvYcn �%icarex ©1988.2015 ACORD C(R"""""'9e"""ae"�A'"� ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD v `0