PAINT BLAST US (STENCIL BLAST US, INC)

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aco20r CERTIFICATE OF LIABILITY INSURANCE lle� DATE(MM/DDNYYY) 10/29/2024 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: Rena Prasad Excelsure Insurance Services PHONE 18377 Beach Blvd., Ste. 325 (714) 796-1000 AC No:(877) 987-5051 E-MAIL ADDRESS certs@excelsure.com Huntington Beach CA 92648 INSURER(S)AFFORDING COVERAGE NAIC9 INSURERA: Kinsale Insurance Company 38920 INSURED INSURER B: Employers Compensation Insurance 11512 Stencil Blast US, Inc. INSURERC: DBA: Paint Blast US Po Box 1196 INSURERD: INSURER E: Sunset Beach CA 90742 INSURER F: COVERAGES SA CERTIFICATE NUMBER: Cart ID 16469 (77) 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. ILTR TYPE OF INSURANCE ADOL SUHR POLICYNUMBER POLICY EFF MMIDDIYYYY1 POLICY EXP (MMIDD/YYYY1 LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE �% OCCUR Y Y 0100294432-0 04/15 /2 02 4 04/15/2025 EACH OCCURRENCE $ 1, 000, 000 PREMSES Fa occurrence $ 100,000 MED EXP(Any one person) $ 5,000 PERSONAL S ADV INJURY $ 11000,000 AGGREGATE LIMIT APPLIES PER: POLICY JE'CT 11 LOC GENERALAGGREGATE $ 2,000,000 GEN'L PRODUCTS-COMP/OPAGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANYAUTO J OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE Par accident S $ A UMBRELLALIAB X OCCUR 0100294469-0 04/15/2024 - 04/15/2025 EACH OCCURRENCE $ 11000,000 AGGREGATE $ 1,0001000 X EXCES$LIAe CLAIMS -MADE DEO I I RETENTION$ $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANYPROPRIETOR/PARTNEMEXECUTIVE OFFICEWMEMBEREXCLUDEDP 51 NIA HIG570434900 08/30/202 4 08/3 0/2 02 5 PER OTH- X STATUTE ER E.L. EACH ACCIDENT $ 11000,000 E.L. DISEASE -EA EMPLOYEE $ 11000,000 (Mandatory In NH) If yes, describe under E.L. DISEASE -POLICY LIMIT $ 11000,000 DESCRIPTION OF OPERATIONS below $ DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACOR0101, Additional Remarks Schedule, may be attached If more space is required) The Certificate Holder, as required by written contract or agreement, is Additional Insured with respects to the General Liability, as par form CG 20 10 12 19, including Competed Operations as per form CG 20 37 12 19, Primary and Non -Contributory Wording as per form CAS5003 0717 and Waiver of Subrogation as per form CAS4002 0110. Waiver of Subrogation is included on the Workers Compensation policy as per form WC 04 03 06 (Ed. 4-84).RE: Public Arts - Crosswalk Art & Sidewalk Poetry I Address: 20 Civic Center Plaza Santa Ana, CA 92701 Thirty (30) day prior notice in case of cancellation of policy CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Santa Ana - Public Works Agency ACCORDANCE WITH THE POLICY PROVISIONS. 20 Civic Center Plaza AUTHORIZED REPRESENTATIVE Santa Ana CA 92701 ' V V ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD APPROVED Page 1 of 2 Sy Cynthia Mora at 1:39 pm, Nav21, 2024