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Samantha Digitally signed
<br />A� H CERTIFICATE OF LIABILITY IK*URANCE bySamanthatha
<br />Lambert
<br />. DAT012612D/YYYY)
<br />E (MMID
<br />to/zs/zoz3
<br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONF RFr S NO j21GHT� UP.d)aVC' 20MFdC4$E HOLDER. THIS
<br />CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND O VE O ,BY THE POLICIES
<br />BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THEM S�N a It�lR(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 endorsements).
<br />PRODUCER
<br />CONTACT Kim Unland
<br />SfateFaIT11 State Farm Insurance
<br />Greg Davis, Agent, ChFC, CCU, RIPC, LTC?
<br />aCONN E,h: 714-633-3020 ext 3 ac No: 714-633-2572
<br />E-MADDAIL REES. kim@gregdavis.biz
<br />INSURER(3)AFFORDING COVERAGE
<br />NAIL#
<br />® 1500 E Katella Ave, Suite 6
<br />INSURER A: State Farm General Insurance Company
<br />25151
<br />Orange CA 92867
<br />INSURED
<br />INSURER B: State Farm Mutual Automobile Insurance Company
<br />25178
<br />Sarah Johnston
<br />INSURER C :
<br />Showtime Ballet Company, Inc
<br />INSURER D:
<br />410 W 4th St, 2nd floor
<br />INSURER E :
<br />Santa Ana CA 92701
<br />INSURER F:
<br />COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
<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 />SUB
<br />WVD
<br />POLICY NUMBER
<br />POUCYEFF
<br />MMIDDIYYYY
<br />POLICY EXP
<br />MWDD/YYYY
<br />LIMITS
<br />COMMERCIAL GENERAL LIABILITY
<br />EACH OCCURRENCE
<br />$ 1,000,000
<br />CLAIMS -MADE �X— OCCUR
<br />DAMAGE RENTED
<br />$ 300,000
<br />MED EXP(Any one person)
<br />$ 5,000
<br />PERSONAL S ADV INJURY
<br />$ 1,000,000
<br />A
<br />Y
<br />Y
<br />92-CR-P647-1
<br />07/23/2023
<br />07/23/2024
<br />GENI AGGREGATE LIMIT APPLIES PER:
<br />GENERAL AGGREGATE
<br />$ 2,000,000
<br />RO-
<br />X POLICY J ECTT LOC
<br />PRODUCTS - COMP/OP AGO
<br />$ 2,000,0000
<br />$
<br />OTHER
<br />1
<br />AUTOMOBILE
<br />LIABILITY
<br />92-CR-P647-1
<br />07/23/2023
<br />07/23/2024
<br />EO aBI tlED SINGLE LIMB
<br />$
<br />BODILY INJURY (Per person)
<br />$ 1,000,000
<br />X
<br />ANY AUTO
<br />B
<br />X
<br />OWNED SCHEDULED
<br />AUTOS ONLY X AUTOS
<br />BODILY INJURY (Per accident)
<br />$ 1,000,000
<br />X
<br />HIRED AUTOS ONLY X AUTOS ONLDY
<br />Per aWdeni
<br />$ 1,000,000
<br />$
<br />UMBRELLA LIAR
<br />OCCUR
<br />EACH OCCURRENCE
<br />$
<br />AGGREGATE
<br />g
<br />EXCESS UAB
<br />CLAIMS -MADE
<br />DED I I RETENTION $
<br />$
<br />A
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY
<br />ANY PROPRIETORIPARTNERIEXECUTNE YIN
<br />OFFICER/MEMBER EXCLUDED? ❑Y
<br />N/A
<br />92-CR-P647-1
<br />07/23/2023
<br />07/23/2024
<br />X PER OTH-
<br />WE ER
<br />$
<br />E.L. EACH ACCIDENT
<br />$ 1,000,000
<br />E.L. DISEASE -EA EMPLOYE
<br />$ 1,OOQ000
<br />(Mandatory In NH)
<br />If yes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />E.L. DISEASE_ POLICYLIMIT
<br />$ 1,000,000
<br />�:,,• WdMma�lledDMlLn y2
<br />DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schadule, may be attached if more space is required) th`AflrlEl}GMPROV®BY:
<br />Description: Dance Instruction SA±7111h iA+wcrdRa (F,nw,T
<br />Rua management Supervisor`
<br />Lessor: Showtime Dance Inc Owner: Simple Venture, LLC 01
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />City of Santa Ana
<br />Risk Management Division
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />AUTHORIZED REPRESENTATIVE
<br />20 Civic Center Plaza
<br />Completed by an authorized State Farm representative. If signature
<br />Santa Ana CA 92702
<br />is required, please contact a State Farm agent.
<br />@ 1988-2015 ACORD CORPORATION. All riahts reserved
<br />ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
<br />10014M 132849.14 04-132022
<br />
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