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AC" CERTIFICATE OF LIABILITY INSURANCE DATE(MMlDDIYYYY) <br /> 1 010 9/2 02 5 <br /> THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS <br /> CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES <br /> BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(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 endorsement(s). <br /> PRODUCER NAME CT Automatic Data Processing Insurance Agency, Inc. <br /> Automatic Data Processing Insurance Agency, Inc. PJCO"Iu E=st: 1-800-524-7024 Fa c,No): <br /> E-MAIL <br /> ADDRESS: <br /> 1 Adp Boulevard INSURERIS)AFFORDING COVERAGE NAIC# <br /> ROseiand NJ 07068 INSURER A: The Pie Insurance Company 21857 <br /> INSURED BACKHAUS DANCE <br /> iNSURER.B <br /> INSURER C <br /> 4365 Johanna Ave INSURER D <br /> INSURER E: <br /> Lakewood CA 90713 INSURER F: <br /> COVERAGES CERTIFICATE NUMBER: 4593813 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 ADDL SUBR POLICY EFF POLICY EXP <br /> LTR TYPE OF INSURANCE INSD I wVD POLICY NUMBER MM1DDiYYYY MM1DDIYYYY LIMITS <br /> COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S <br /> DAMAGE To N D <br /> CLAIMS-MADE OCCUR PREMISES Ea occurrence $ <br /> MEd EXP(Any one perscn) S <br /> PERSONAL&ADV INJURY S <br /> GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S <br /> POLICY❑EC- ❑LOC PRODUCTS-COMPIOPAGG 5 <br /> OTHER: $ <br /> AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S <br /> Ea accident <br /> ANY AUTO BODILY INJURY(Per person) S <br /> OWNED F SCHEDULED <br /> AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ <br /> HIRED NON-OWNED PROPERTY DAMAGE <br /> AUTOS ONLY AUTOS ONLY Per accident $ <br /> UMBRELLA LIAR OCCUR EACH OCCURRENCE 5 <br /> EXCESS LIAB CLAIMS-MADE AGGREGATE 5 _ <br /> DFD RETENTION 5 5 <br /> WORKERS COMPENSATION PER OTH- <br /> AND EMPLOYERS'LIABILITY YIN STATUTE I ER <br /> ANY PROPRIETOPWARTNERJEXECUTIVE E.L.EACH ACCIDENT 5 1,000,000 <br /> A OFFICERIMEMBER EXCLUDED? ® N 1 A IN VVCPI1310148001 0910712025 0910712026 <br /> (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S 1,000,000 <br /> It yes,describe under <br /> DESCRIPTION OF OPERATIONS below EL,DISEASE-POLICY UNIT S 1,000.000 <br /> DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES ACORD 101,Additional Remarks Schedule,may be attached Ff more space is required) <br /> Tu Tran °`9a,IIYsl9neu by <br /> Tu Tree Nguyen <br /> r�' Date:2025.r2.l79 <br /> I�t g u y e n 0740-5a 06,00' <br /> APPROVED <br /> By Tu Tram Nguyen at 7:40 am,Dec 09,2025 <br /> CERTIFICATE HOLDER CANCELLATION <br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br /> City of Santa Ana,Attn:Parks,Recreation and Community THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br /> Services Agency. M-23 ACCORDANCE WITH THE POLICY PROVISIONS. <br /> 20 Civic Center Plaza <br /> AUTHORIZED REPRESENTATIVE <br /> Santa Ana CA 92701 <br /> 3 O 1988-2015 ACORD CORPORATION. Ail rights reserved. <br /> ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD <br />