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CERTHOLDER COPY <br /> SP <br /> STATECOMPrN5ATION P.O. BOX 8192, PLEASANTON, CA 94588 <br /> INSURANFUN <br /> w <br /> CE <br /> CERTIFICATE OF WORKERS' COMPENSATION INSURANCE <br /> ISSUE DATE: 04-22-2025 GROUP: <br /> POLICY NUMBER: 9304403-2024 <br /> CERTIFICATE ID: 24 <br /> CERTIFICATE EXPIRES: 08-26-2025 <br /> 08-26-2024/08-26-2025 <br /> THE CITY OF SANTA ANA SP <br /> PARKS, RECREATION, AND COMMUNITY SERVICES <br /> 20 CIVIC CENTER PLZ <br /> SANTA ANA CA 92701-4058 <br /> This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the <br /> California Insurance Commissioner to the employer named below for the policy period indicated. <br /> This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer. <br /> We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration. <br /> This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded <br /> by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document <br /> with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance <br /> afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy. <br /> Authorized Representative President and CEO <br /> EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. <br /> ENDORSEMENT #0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2025-04-22 IS <br /> ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED: <br /> THE CITY OF SANTA ANA <br /> ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 08-26-2024 IS <br /> ATTACHED TO AND FORMS A PART OF THIS POLICY. <br /> ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2025-04-22 IS <br /> ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: <br /> THE CITY OF SANTA ANA <br /> ENDORSEMENT #1651 - TED HOLCOMB P - EXCLUDED. <br /> ENDORSEMENT #1651 - UANET HOLCOMB S,T - EXCLUDED. <br /> EMPLOYER <br /> ELITE SPECIAL EVENTS, INC SP APPROVED <br /> 11278 LOS ALAMITOS BLVD #101 <br /> LOS ALAMITOS CA 90720 By Tu Tran Nguyen at 12:11 pm,May 01,2025 <br /> [DOG,CN] <br /> (REV.7-2014) PRINTED : 04-22-2025 <br />