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HomeMy WebLinkAboutGilroy Gardens - Insurance CertificateAC40RO CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) Ili 04/05/2017 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 PRODUCER. REPRESENTATIVE OR I C T 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'ricihts to the certificate holder in lieu of such endorsement(s). PRODUCER .. - ,. -. :' CONTACT EVENTS H� ATTRACTIONS;—. ;_ K&K' INSURANCE GROUP, INC. P; O BOX 2338.. r.. - PHONE 800- 553 -8368 2604 59 5624 No, Ext _ (A /C,No) —_ - -M —AIL- FORT- WAYNE, IN- 46801- -. ...._...._ _ -- ..___ _.._.. _. -- -... _. ' -. _ _ _ . ADDRESS: — INSURER(S) AFFORDING COVERAGE,, ,. -_:: `,_: ,` . NAIC # }�,;� -, <. INSURER A: NATIONAL CASUALTY COMPANY 11991 INSURED' - INSURER B: SCO17SDALE INDEMNITY.COMPANY' • - 1.5580;- GILROY GARDENS FAMILY THEME PARK INSURER C: -- -- 3050 HECKER PASS HIGHWAY GILROY, CA 95020 - - INSURER D: _ $300,000 INSURER E: EXCLUDED INSURER F: LIQUOR LIMITS - $1,000,000 /$1,000,000A_GG COVERAGES CERTIFICATE NUMBER: C62817 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, INSR. LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF MM /DD/YYYY POLICY EXP MM /DD/YYYY LIMITS. B X COMMERCIAL GENERAL LIABILITY _ KKI0000020819700 3/30/2017 3/30/2018 EACH OCCURRENCE $1,000,000 CLAIMS -MADE OCCUR _ 12:01 AM 12:01 AM DAMAGE TO RENTED PREMISES Ea Occurrence _ $300,000 MEDEXP (Any one person) EXCLUDED X LIQUOR LIMITS - $1,000,000 /$1,000,000A_GG PERSONAL 8 ADV INJURY $1,000,000 - GENERAL AGGREGATE $0 - •GEN'LAGGREGATE LIMITAPPLIE5 PER: PRODUCTS — COMP/OP AGG $5;000,000 POLICY ❑P ROJECT LOC -: -_.- �LEGAL.LIAB TO PARTICIPANTS = PROFESSIONAL LIABILITY OTHER. _. _ ._.' -B. AUTOMOBILE- LIABILITY ANY -AUTO_ KKI000002081:9800 — 3/30/2017 12 01 AM 3/30/2018 - 12:01 -AM E LIMIT Ea accident .-__ —_- $1000,000 ... . BODILYUNJURY: (Per persan)� -� -' AUTOS) SCHEDULED AUTOS S ONLY _ ,.;.;, .;, _'_.`; . _•; - ": BODILY INJURY (Per accident) Per accident) 'HIRED :• . _ NON- OWNED X AUTOS ONLY X AUTOS;ONLY- - - - A UMBRELLA'LIAB X OCCUR XK00000020819900 3/30/2017 3/30/2018 EACH OCCURRENCE $4,000,000 EXCESS LIAB CLAIMS -MADE 12:01 AM 12:01 AM X AGGREGATE $4,000,000 ._.__...� - -- -- -- ---- -- ----- DED RETEN710N A WORKERS OMPENSATI N AND EMPLOYERS ".LIABILITY ANYPROPRIETOR /PARTNER/ Y/N EXECUTIVE OFFICER/MEMBER N/A WCCO033122604 3/30/2017 12:01 AM 3/30/2018 12:01 AM X STATUTE OTHER _ Lj EI_EACHACCIDENf $1,000,000 —_ - - -~ —_ — E.L. DISEASE_ Ili EMPLOYEE - -- - -- — $1,000',.000. EXCLUDED? (Mandatory in NH) It yes, describe under f I DESCIRIN'ITON OF OPERATIONS below E.L. DISEASE — POLICY LIMIT $1.,000,000 PARTICIPANT ACCIDENT ADaD Primary Medical Excess Medical Weekly Indemnity 'DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) SEE ATTACHED ADDENDUM CERTIFICATE HOLDER CANCELLATION CITY OF GILROY SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE 7351 ROSANNA STREET EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. GILROY, CA 95020 AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) ©1988 -2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: LOC #: CERTIFICATE: C62817 ADDITIONAL REMARKS SCHEDULE DATE ISSUED: Page - 1 of — 1 .AGENCY NAMED INSURED K &'K INSURANCE GROUP, INC. GILROY GARDENS FAMILY THEME PARK P.O. BOX 2338 3050 HECKER PASS HIGHWAY FORT WAYNE, IN 46801 _ ' GILROY, CA 95020 POLICY NUMBER SEE ACORD 25 EFFECTIVE DATE CARRIER SEE ACORD 25 SEE ACORD 25 4DDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACOrd25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE _ THE CITY OF GILROY, ITS OFFICERS. OFFICALS, AND EMPLOYEES ARE ADDED AS ADDITIONAL INSURED, BUT ONLY FOR LIABILITY CAUSED IN WHOLE OR IN PART. BY THE ACTS OR OMISSIONS OF THE NAMED INSURED. ACORD 101 (2008101) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD MBADDERS CERTIFICATE OF LIABILITY INSURANCE °A�'/30/16 ACORDT" 3/30/16 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 K & K Insurance Group, Inc. GONTALT NAME: LEISURE, P.O. Box 2338 Fort Wayne, In 4680.1 PHONE. N'Eat 800-- 553-8368 260- 459 -5624 M.._. -_ ii ". ___.. .._...... �Ci__..._._.._...._....... _ ,._.... MMlDO/YYYV ADDRESS: KK. EVENTSATTRACTIONS @KANDKINSURANCE.COM INSURERS) AFFORDING COVERAGE NAIC II' X COMMERCIAL GENERAL LIABILITY INSURER A NATIONAL CASUALTY COMPANY 11991 INSURED GILROY GARDENS FAMILY THEME PARK _ . "INSURERS. SCOTTSDALE INDEMNITY COMPANY ._..__15580 3050 HECKER PASS HWY INSURER B GILROY, CA 95020 INSURER D: INSURER IE 12:0 12 : 01AM INSURER F: _ _ 300000 c:vu wcles CERTIFICATE NUMBER: 1844624 REVISION NUMBER: THIS IS I - C-111 , 111AT THE POLICIES 5. THE INMAM NA--M'-5D -'ABOVE 'FOR THE POY P I ER1100 INDICATED NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTH£R 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 NC =NOT COVERED NS TYPE OF INSURANCE INS* SUSR WVD POLICY NUMBER MMlDO/YYYV MMlDDIWYX LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 1000000 B CLAIMS MADE I g IOCCUR 12:0 12 : 01AM aMAGETORENTEO PREMISES (Ea occurrence _ _ 300000 MED EXP (Arty one person) Owners & Contractors jjj KKI0006233700 3 / 30/1 3/30/17 Y _ NC�� LXQtJOR. LiA$ S1M. QCC AGG 1 PERSONAL SADVINJURYN 1000000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE NONE __. POLICY FPROJECT f­­ LOC ..... .... __�._. PRODUCTS- COMPIOPAGO ._. __,.. 5000000 OTHER: _._. Part _L 1 Liab ...... �_._. _ :7µ AUTOMOBILE LIABILITY Ea Accident L 1000000 X ANY AUTO 12: 12: BODILYINJURY(Perperson) B .._:... _. KKI0006233700 3/300 /1 3/30/10/1 7. OWNED AUTOS ONLY AUTOSULED -..: __.._......__.._�. ".._..._ BODILY INJURY (Per accident) X HIRED AUTOS ONLY X NON -OWNED PROPERTY DAMAGE' AUTOS ONLY (Per accident) UMBRELLALIAB OCCUR EXCESS UAB .CLAIMS 12: -01 12:OlAM EACHOCCURRENCE 4000000 A X -MADE XK00006233900 3/30/1 3/30/17 AGGREGATE 4000.000 DED RETENTION _..... "_._ ".._ __.,. _.... . . WOF KERS COMPENSATI AND EMPLOYERS' LIABILITY YIN. X 'PER - r ATUE1 OTHER C ANY. PROPRIETOR)PARTNER/ I EXECUTIVEOFFICER/MEMBER I WC00033122603' 12 :01 3/30/1 12 :01AM 3/30/17 ,y ' EL. EACH ACCIDENT _ 1004000 EXCLUDED( N!A' tMa watc q'Ift H) describeor E L DISEASE — EA EMPLOYEE ......... _ ... 1000000 ......... �.. E L. DISEASE— POLICY LIMIT ___ ".....�.�.�.�._..... 1000000 (DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS! LOCATIONS /VEHICLES (Attach .ACORD itli, Additional Remarks Schedule, may be attached if more space is required) *SEE ATTACHED ADDENDUM" CITY OF GILROY 7351 ROSANNA STREET GILROY, CA 95020 ACORD 25 (2016103) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE_ THEREOF, NOTICE WILL BE nlELIVERED IN ACCORDANCE WITH THE POLICY PROVISION& l J 01988- 2015ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ACORDTM AGENCY CUSTOMER ID: LOC # CERTIFICATE: 1844624 DATE ISSUED: ADDITIONAL REMARKS SCHEDULE 3/30/16 Page — 3 of 3 AGENCY NAMED INSURED K & K INSURANCE GROUP, INC. GILROY GARDENS FAMILY THEME PARK 3 050 HECKER PASS HWY GILROY, CA 95020 POLICY NUMBER GL KKI0006233700 WC WCCO033122603 .AL KKI0006233700 EX XK00006233900 ..... ...... . CARRIER NAIC CODE SEE ACORD 25 > IVEDaTE: SEE ACORD 25 THIS ADDITIONAL REMARKS FORM IS ASCHEDULE TO ACORD FORM, I FORM NUMBER: 80.0RD -2 FORM TITLE: gTTFT THE CITY OF GILROY, ITS OFFICERS, OFFICIALS, AND EMPLOYEES ARE ADDED AS, ADDITIONAL INSURED, BUT ONLY FOR LIABILITY CAUSED, IN WHOLE OR IN PART, BY THE ACTS OR OMISSIONS OF THE NAMED INSURED. ACORD 101 (2008/01) ® 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD CONIVERCIAL GENERAL LIABILJTY CG 20110413 � � �� • - - �� e� rte. � - • � -� � s - a 1 ;�*k J ow, b-1, L, �CA-""'69 ' This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART Designadon Of Premises (Part Leased To You): THOSE PREMISES ON FILE WMTH US UNLESS SPECIFICALLY DECLINED. Name Of Parson(s) Or Orgm abon(s) (Addtional Insured): THOSE MANAGERS/LESSORS ON FILE VUTH US UNLESS SPECIFICALLY DECLINED. AdC6UMW Pren7unY INCLUDED Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II - VVho Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability arising out of the ownership, maintenance or use of that part of the premises leased to you and shown in the Schedule and subject to the following additional exclusions: This insurance does not apply to: 1. Any "occurrence" which takes place after you cease to be a tenant in that premises. 2 Structural alterations, new construction or demolition operations performed by or on behalf of the person(s) or organization(s) shown "in the Schedule. 2 If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. EL With respect to the insurance afforded to these additional insureds, the following is added to Section Ill. - LirretCs Of Irmffance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or However. 2 Available under the applicable Limits of 1. The insurance afforded to such additional Insurance shown in the Declarations; insured only applies to the extent permitted by whichever is less. law, and This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. CG 20110413 © Insurance Services CITice, Irr-, 2012 Page 1 of 1 AXIS 8000(08/10) CERTIFICATE OF INSURANCE 1 03/28/2013 PRODUCER American Specialty Insurance & Risk Services, Inc. 142 North Main Street Roanoke, Indiana 46783 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. INSURED Gilroy Gardens Family Theme Park, Inc. 3050 Hecker Pass Highway Gilroy, CA 95020 INSURERS AFFORDING COVERAGE INS. A: AXIS Insurance Company INS. B: INS. C: CERT NUMBER: 1001095155 COVERAGES THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOT WITHSTANDING 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, INS LTR POLICY TYPE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS A GL AXGL02103695 -13 03130/2013 12:01 a.m. 03/30/2014 12:01 a.m. General Aggregate 5,000,000 Products-Completed Operations Aggregate 5,000,000 Personal and Advertising In try 1,000,000 Each Occurrence 1,000,000 Damage to Premises Rented to You (Any One Premises 100,00() Medical Expense Limit (Any One Person Excluded DESCRIPTION OF OPERATIONS /LOCATIONSNEHICLES /EXCLUSIONS ADDED BY ENDORSEMENT /SPECIAL PROVISIONS - The Certificateholder is only an additional insured with respect to liability caused by the negligence of the Named Insured as per Form AXIS 1003 - Additional Insured- Certificateholders, effective March 30, 2013, CERTIFICATE HOLDER CANCELLATION CITY OF GILROY 7351 ROSANNA STREET GILROY, GA 95020 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE II- 4 . American Specialty Insurance & Risk Services, Inc. also conducts business as A.S.I.R.S.I. Insurance Agency in the state of California. ACORD,. MBADDERS CERTIFICATE OF LIABILITY INSURANCE DATE(MINDDlYYYY) 3/30/16 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(les).must have ADDITIONAL INSURED provisions or be endorsed. If _ conditions m require an endorsement A statement on P Y Po ay e9 erhficate thi; 51 endorsement(s)ICies tloes not confer rights to the certificate holder !�. PRODUCER.''. K &_ K.Insurance Group, Inc, NAM: EA LEISURE P.O. Box 2338 Ir6IIE - - -- —"FAX � ..�.. No..Ext): 800-553-8368, AC No 260-459-5624 (... L Fort Wayne, In 46801 .(A!C _. E -MAIL _ Owners & Contractors KKI0006233700: 3/30/1 ADDRESS: KK. EVENTSATTRACTIONS @KANDKINSURANCE.COM NC INSURER(S AFF ORDING COVERAGE NAIL II . ... ... ._...___..... _. _. .. _INSURER A. NATIONAL CASUALTY COMPANY i 11991 INSURED GILROY GARDENS FAMILY THEME PARK INSURER B: SCOTTSDALE INDEMNITY COMPANY 15580 3050 HECKER PASS HWY N _ . IN 11 SURER C. .. : NA'1 "`TCYNAI, _CASUALTY COMPANY——— ? 11991­­ " GILROY, CA 95020 INSURER D: ,_..,.. POLICY (PROJECT ;LOC ! INSURER E: 50000.. U0 INSURER F: UUVtKACstS Ut FCIIt -ICAIE NUR95ER: 1844624 REVISION NUMBER_ HI IF THAT THE POLICIES O INSURANCE LISTED OW HAVE N ISSUED , V r . ' HE P710,1 ,' PERIOD Nc I ATED'. 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, r.Y.CLU510NS AND CONDITIONS OF SUCH POLICIES, _LIMITS SHOWNiMAY HAVE BEEN REDUCED BY PACD CLAims NC =NOT COVERED iLTR - TYPE OF INSURANCE IADDL, POLICY NUMBER I POLICY EFF ITRI INSD =W1/D,.: •fMM /DD/YYYY)�(MMIDDIVWY)i...�. O L i LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE , 100000 ;0 ( CLAIMS-MADE I (OCCUR '. B' XX 12:01 _ I)AWA65 TO REN 80 12 0 1A PREMISES (Ea occurrence T .......,,. ._ 300000 Owners & Contractors KKI0006233700: 3/30/1 3/30/17[ MED EXP (Anyone person) NC X 's,(�UOR i.,STaB ._,M1M CSCC /Lt - G fPERSONALBADV INJURY 1000000 GENT AGGREGATE LIMIT APP LIES'PER: GENERAL AGGREGATE NONE POLICY (PROJECT ;LOC ! PRODUCTS- COMP /OPAGG 50000.. U0 `.OTHER: Part_ Lgl Liab NC AUTOMOBIL E'LIABiUTY _ f Ea Acc dent) 1000000 2 1 12: AN X ANY AUTO. KKI 00062 3 3 70 0;= 3/30/1( 2 1AM 1 0 BODILY INJURY (Perpersan) 3/30/17.,.... " SCHEDULED OWNED AUTOS ONLY AUTOS i BODILY INJURY (Peraccident) ,..., X.: 'HIRED AUTOS.ONLY I.X %NON -OWNED PRbPERTY DAMAGE _ m.. . , • AUTOS ONLY t fPer accident) _ ,-„ UMBRELLALlAO h ,OCCUR (EACH OCCURRENCE 4000000 12 : 01 A X E7(CE99LIA8 CLAIMS MADE XK0000:6233900; 3/30/1 ................... . 12: OlAM'� AGGREGATE 3/30/17(... _ ..... _ a0.0OC10D DED RETENTION j WORKERS COMPENSATION ± X PER- STATUE OTHER AND EMPLOYERS' LIABILITY Y 1 N ( ANY PROPRIETOR /PARTNER/ 1 1201AY 12 C1AM EL EACH ACCIDENT — 1000000 CF EXECUTIVE OFFICER /MEMBER ;NlA WCCO0331226031 3/30/1( .EXCLUDED? 3/30/17 ..._ ...... _ _., _. .� ..... .......... _._�.__.... ,;(Polandato y:7n y1{i ? ., j E L DISEASE EA EMPLOYEE 1000000 YaCRiPTIOMOF OPERATIONS below I. ! ( _... �.:' E.L.DISEASE — POLICYLIMIT I 1000000 i 4 DESCRIPTION OF OPERATIONS ('LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, may be attached R more space is required) "StE ATTACHED ADDENDUM- Ii V L4Y -Il. AI \iJ LI..L.nl I VI\ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CITY OF GILROY THE EXPIRATION DATE THEREOF, NOTICE WILL 'BE SLIVERED IN 7351 OF GILROY STREET ACCORDANCE WITH THE POLICY PROVISION GILROY, CA 95020 AUTHORIZED R £NTATI ACORD 25 (2016103) © 1988- 2015ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: . ... _._...... ........ ..� LOC # CERTIFICATE: 1844624 DATE ISSUED: 3/30/16 ACORD,. ADDITIONAL REMARKS SCHEDULE Page of I AOENCV NAMED INSURED K & K INSURANCE GROUP, INC. GILROY GARDENS FAMILY THEME PARK - .---- ,.- .... - - -- - -- 3050 HECKER PASS HWY GILROY, CA 95020 POLICY NUMBER GL KKI0006233700 WC WCCO033122603 AL KKI0006233700 EX XK00006233900 I - .. . ............. CARRIER NAIC CODE SEE ACORD 25 EFFECTIVE DATE: SEE ACORD 25 MIJLJI I IVIVML MCIVIAMnO F IS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, RM NUMBER: gQ0.RD _ FORM TITLE: _�EgZIFICA � Q�I, Ag T.T y IN,� RAND THE CITY OF GILROY, ITS OFFICERS, OFFICIALS, AND EMPLOYEES ARE ADDED AS ADDITIONAL INSURED, BUT ONLY FOR LIABILITY CAUSED, IN WHOLE OR IN PART, BY THE ACTS OR OMISSIONS OF THE NAMED INSURED. ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD PMALDENEY DATE (MMIDDIYYYY) ACORD,. CERTIFICATE OF LIABILITY INSURANCE 3/28/14 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;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 K &"'-k �Insurance Group, Inc. CONTACT NAME: LEISURE P.O. Box 2338 Fort Wayne, In 46801 PHONE 800 -553 -8368 FAX 260 -459 -5624 AIC No.Ext: A/C No: ADDRESS: KK• EVENTSATTRACTIONS @KANDKINSURANCE.COM INSURER(S) AFFORDING COVERAGE NAIC O INSURER A: NATIONAL CASUALTY COMPANY 11991 INSURED GILROY GARDENS FAMILY THEME PARK INSURER 8:SCOTTSDALE INDEMNITY COMPANY 15580 3050 HECKER PASS HWY INSURERC: COMMERCIAL GENERAL LIABILITY GILROY, CA 95020 INSURER D: 12:01AM INSURER E DAMAGE TO RER= PREMISES Ea occurrence 300000 INSURER F: CLAIMS-MADE FX OCCUR COVERAGES CERTIFICATE NUMBER: 1739660 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POICIES 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 CERnFICATE MAY BE D HEFiNF(L�=�8TSI& E O ALL THE TERMS, UCH EXCLUSIONS AND CONDITIONS OF POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCEDL BY PAID CLAIMS. IN LTR TYPE OF INSURANCE INS WVD POLICY NUMBER MWDDNYYY MMIDDNYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE 1000000 B X COMMERCIAL GENERAL LIABILITY 12:01AM 12:01AM DAMAGE TO RER= PREMISES Ea occurrence 300000 CLAIMS-MADE FX OCCUR Y KKI0004343500 3/30/14 3/30/15 MED EXP (Any one person) NONE PERSONAL & ADV INJURY 10000.00 Owners & Contractors GENERAL AGGREGATE NONE GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS- COMP /OPAGG 5- 0- 0� 000_.0 _ - 47 POLICY PROJECT LOC Part Lgl Lab NC B AUTOMOBILE LIABILITY,., ANY AUTO _. _ KKI0004343500 12:01AM 3/30/14 12:01AM - 3/30/15 COMBINED SNGL LIMIT Academ 1000000 X - - ,- .. BODILY INJURY (Per person),, .. ... � BODILY INJURY (Per accident) - SCHEDULED ALL OWNED�AUTOS - . ' AUTOS �.. � � ” '. X - A -. - .. X, - HIRED AUTOS ":' '� AUTOS - , ' -''i PROPERTY DAMAGE •'� �� Per accident)- '' ` "- UMBREL.LAUAB X OCCUR EACH OCCURRENCE 4000000 A EXCESStL4B CLAIMS-MADE MADE XKOD004344600 3/30/14 12:01AM 3/30/15 X AGGREGATE _ DED .RETENTION C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNER/ EXECUTIVE OFFICER /MEMBER EXCLUDED? NIA WCCO033122601 12:01AM 3/30/14 12:01AM 3/30/15 WC S777_7 TORY LIMITS 11 OTHER E.L. EACH ACCIDENT 1000000 E. L. DISEASE -EA EMPLOYEE 1000000 (Mandatory in NH) If yes; describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT 1000000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, Ifmore space Is required) - CERTIFICATE HOLDER IS ADDED AS ADDITIONAL BUT ONLY RESPECTS LIABILITY CAUSED, IN WHOLE OR IN PART, BY THE ACTS OR OMISSIONS OF THE NAMED INSURED CITY OF GILROY 7351 ROSANNA STREET GILROY, CA 95020 ACORD 25 (2010/05) SHOULD ANY OF THE ABOVE DE THE EXPIRATION DATE THIEF ACCORDANCEIyR'H THE POLICY AUTHORIZED SS BE CANCELLED BEFORE WILL BE 4EUVERED IN ®1988 -2010 ACORD CORPORATION. All rights reserved. The.ACORD name and logo are registered marks of ACORD---