Insurance - Costa Mesa Newport Harbor Lions Club - 2019-09-06DATE (MMIDOIYYYY)
AC' RV CERTIFICATE OF LIABILITY INSURANCE
09/06/2019
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONIFERS 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 pollcy(ies) must 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 endorsements).
PRODUCER
CONTACT
NAME: John Adams
D S R I n S U ran Ce
PHONE : 1-800-316-6705a° � No : 847-934-6186
ADDRESS- lionsclubs@dspins..com
1900 E. calf Road, Suite 650
Schaumburg, IL 60173
INSURER AFFORDING COVERAGE NAIc#
INSURER A. AGE American Insurance Company/ 22667
INSURED
INSURER 0:
INSURER C
Costa Mesa Newport Harbor Lions Club
CLAIMS -MADE J
Costa Mesa California
INSURER o :
INSURER E:
INSURER F:
X Aga. Per Named Insured
COVERAGES CERTIFICATE NUMBER; 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 SHORN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
I TYPE OF INSURANCE
L
POLICY EFF POLICY EXP
POLICY NUMBER MMA)DIYYYY MMIDDIYYYY
LIMITS
A
GENERAL LIABILITY
EACH OCCURRENCE a 1,000,000
X COMMERCIAL GENERAL LIABILITY
HDOG71573448 09/01/2019 09/01/2020
PREMISES Ea occurrence) S 1,000,000
CLAIMS -MADE J
MED Ea � �CS 55,000
X Aga. Per Named Insured
PE res. & ADI INJURY S 1,000,000
is $2,000,000
GENERAL AGGREGATE S 10,000,000
PRODUCTS - COMPiOP AGG S 2,000,000
GEML AGGREGATE LIMIT APPLIES PER
POLICY PRO-
JEQ1 L]LCC
s
A
AUTOMOBILE
LIABILITY
ANY AUTO
ISAH25301754 09/01/2019 09/01/2020
COMBINED SINGLE LIMIT
(Ea accident) S1,000,000
BODILY INJURY (Per personj S
ALL AUTOS +tEii SCHEDAUTOS
BODILY INJURY (Per accident) S
HIRED AUTOS AUTOS
AUTOS
PROPERTY DAMAGE S
Per accident`
S
UMBRELLA LIAR
HCLAIMS-MADE
OCCUR
EACH OCCURRENCE S
EXCESS LIAR
AGGREGATE S
DED I I RETENTIONS
S
WORKERS COMPENSATION
I WC STATLI- I JOTH-
AND EMPLOYERS' LIABILITY Y I N
ANY PROPR3ETOPJPARTNERrEXECUTIVE
OFFICE EMBER EXCLUDED,,
N I ►
E L EACH ACCIDENT S
E.L. DISEASE - EA EMPLOYEE S
(Mandatory In NH)
0describe under
E SCRIPTION OF OPERATIONS Wow
E _ DISEASE - POLICY LIMIT S
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule. If more space Is required)
Provisions of the policy apply to the named insureds participation in the following activity during the policy period shown above: costa mesa newport harbor fish
fry sept 20-21-22
The following persons or organizations granting use of real property, including structures thereon are included as Additional Insured(s), but only with respect to
General Liability arising out of the use of premises by the insured shown above and not out of the sole negligence of said additional insured.
*** Costa Mesa Sanitary District, it's elected and appointed officials, agents, officers and volunteers ***
nrts
CANCELLATION
Costa Mesa Sanitary District SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
290 Paularino Ave THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Costa Mesa California 92626 _P? ARM M ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
� 'e*4a4.."
1988.2010 ACORD CORPORATION. All rights reserve{
ACORD 25 (2010/05) The ACORD name and loge are registered marks of ACORD
ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION
Named Insured The International Association of Lions
Endorsement Number
Clubs
21
Policy Symbol
Policy Number
Policy Period
Effective gate of Endorsement
H DO
171573448
109/01/2019 TO 09/01/2020
Issued By (Name of Insurance Company)
ACE American Insurance Company
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING:
COMMERCIAL GENERAL LIABILITY COVERAGE FORM
Name of Person or Organization. Costa Mesa Sanitary District, its elected and appointed officials, agents, officers,
and volunteers, 290 Paularino Ave., Costa Mesa, CA 92626
Persons or Organizations granting use of real property, including structures thereon, to a
named insured
WHO IS AN INSURED (Section 11) is amended to include as an additional insured the
person or organization shown in the Schedule, but only with respect to
liability arising out of your operations or premises owned by, used by or rented to
you.
This insurance does not apply to:
1. Any "occurrence" which takes place after the named insured ceases to have use of
said premises or above items.
2. Structural alterations, new construction or demolition operations performed by
or on behalf of the person or organization as described above.
3. Liability out of the sole negligence of the additional insured.
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