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Villareal Dale: 2022.013000:1 al aann Phone:(714)647-5420 Fax:(714)647.6944 AcoK®® CERTIFICATE OF LIABILITY INSURANCE �.../ DATE(MWDDNYYY) 0112612022 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 Triton of Calif Insurance Services, Inc. 5000 San Juan Avenue Fair Oaks, CA 95628 CONTACT Chris Rudolph NAME, — A/L PHONE E 918 486-1706 a/c No: (816)485-0198 ADDRESS: Chris@tritoninsurance.com INSURERS AFFORDING COVERAGE NAIC# License #: OF41767 INSURER A: Mesa Underwriters Speciality Insurance Co. INSURED TOM BYSTRY INSURER B: INSURER C: DBA: VIDEO ENGINEERING SERVICES INSURER D 915 VVYCLIFFE INSURER E: IRVINE, CA 92602 INSURER F: COVERAGES CERTIFICATE NUMBER: 00003962-9368 REVISION NUMBER: 38 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 rypE OF ADDLSUBR INSD VVID POLICY NUMBER POLICY BEE MMIDD/YYYY POLICY EXP MWDDNYYV LIMITS A X COMMERCIAL GENERAL LIABILITY Y Y MP0004009007964 0210112022 02101/2023 EACH OCCURRENCE $ 1000000 CLAIMS -MADE OCCUR X D RENTED PREMISES RENT rrence $ 100,000 MED EXP(Any one person) $ 5000 PERSONAL &ADV INJURY $ 1000000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2006000 POLICY ❑ JEC LOC X PRODUCTS- COMPIOPAGG $ 2,0005000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ HIRED I I NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LAB CLAIMS -MADE DED RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN PER OTH- STATUTE ER E.L. EACH ACCIDENT $ ANY FROPRIETORIPARTNER/EXECUTIVE ❑ OFFICERIMEMSER EXCLUDED? NIA E.L. DISEASE - EA EMPLOYE $ (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS] LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached If more space Is regalred) The City of Santa Ana, 20 Civic Center Plaza, Santa Ana, California 92701; its officers, employees, agents and representatives are named as additional insureds per CG2010 attached to this policy. The insurance is primary and non-contributory. Certificate of Insurance shall provide thirty (30) day prior written notice of cancellation SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Santa Ana THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Risk Management Division ACCORDANCE WITH THE POLICY PROVISIONS. 20 Civic Center Plaza, 4th Floor AUTHORIZED REPRESENTATIVE tom" ee Re4blm age ne tDveian SANTA ANA, CA 92702 REVIEWED&APPROVED BY: F a�,w R. VaXdl © 1988-2015 ACORD C W� Risk ManageIrl Analyst ACORD 25 (20161031 The ACORD name and loao are registered marks of ACORD Print