HomeMy WebLinkAbout14050131 Certificate of Insurance aco� GERTIFICATE OF LIABILITY INSURANCE onre�Mmioonrrr)
3/21/2014
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY.AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDEft. 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
REPRESENTA7IVE OR�PRODUCER,AND�7HE CER7IFICATE HOCDER.
IMPORTANT: If the certificate holder is an ADDI710NAL INSURED,the policy�ies)must be endorsetl. If SUBROGA710N IS WAIVED,subject to
the[eFms and conditions�of[he.policy,certainpolicies may require an endorsement. A�statement on this certificate does not confer rights to the
certificate holder;in iieu of such endorsement s .
FRO�UCER NTA T
NAME:
Britton Gallagher PHONE Fnx
One Cleveland Center, Floor 30 � - - A1C "°: - -
E MAIL
1375 EasE9th Street aooaess:
Cleveland OH 44114 INSURER 5 AFFORDINGCOVERAGE I NAICp
INSURERA:({XI �f
INSURED INSIIRERB: . f1 I fl .
USA Halloween Planet Inc. iNSUReac:Ev mni I r . 1
dba USAFireworks
7800 Records St., Ste.A INSUftERO:
Indianapolis IN 46226 INSURERE:
INSURER F: I
COVERAGES CERTIFICATE NUMBER:�680299135 REVISION NUMBER:
THIS IS TO CERTIFV 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 ANV CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY�BE ISSUED OR MAY PERTAIN, THE INSUR4NCE AFFORDED BY�THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDIT�ONS'OF SUCH POLICIES.LIMITS SHOWN MAV HAVE BEEN REDUCED BV PAID ClAIMS.
��Sq TVPEOFINSURANCE ANSR NND POLICYNUMBER MML�OIYVYY MMIDDYM'YV LIMITS
C GENERALLIABIIITV G�hintle� /12014 I1I2015 EqCHOCWRRENCE $1,�00,000
x COMMERCIALGENERALLIA8ILITV DAMA ET RENTED
PREMISES Eaocwrrence 3500,000
CLAIMS-MADE � OCCUR MED EXP(Any ane pe5on) $
I PERSONAL 8 ADV INJURY 32,000.000
GENEanLAGGREGATE I$z.000.000
GEN'LAGGRpGATELIMITAPPLIESPER'. PROOUCTS-COMP/OPAGG $2,000,0�0
POLICY PR� X LOC $
AUTOMOBILE LIABILITY
Ea accitlent
ANYAUTO BODILYINJURY�Perpersan) I $
ALLOWNE� SCHEOULED
AUTOS AUTOS BO�IIYINJURY(PereccldenQl$
NON-OWNED PROPERTVOAMAGE $
HIRED AUTOS AUTOS Per accident
$
A IUMBRELLAUAe X IOCCUR EAU753088 /Y!2014 . /1I2015 EACHOCCURRENCE 34.000,000
X E%CESS LIAB CLAIM$-MA�E AGGREGATE $4,000,000
DEO RETENTION$ 8
g wOftKERSCOMPEN5aT10N� ARIN33388(IN) �/t0I2014 �2/t012015 X WCSTATU- X OTH-I
AND EMPLOYERS'LIABILIN Y 1 N �"
ANVPROPftIETORIPARTNEWEXECUTIVE❑ N�A ELEACHAGCIDENT $500,000
OFFlCERIMEMBEREXCLUDED?
(MantlatoryinNH) ELDISEASE-EAEMPLOVE $500,000
lfyes,tla5cn0eunder
�ESCRIPTIONOFOPERATIONSbelow EL.OISEASE-POLICYLIMIT $500,000
OESCRIPTION OF OPERATION51 LOCATIONS�VEHICLES (AttacM1 qCORO 101,AtlEltional RemarFS Schetlule,if more space is requiretl) I
*`Add itional I n su red"
Stand�Locationi�13664 N. Meridian St., Carmel, INA6032
Stand;Operatols'Name: USA Halloween Planet,lnc.
Candowner'SNamei�B�ixmor HTG SPE 5 LLC
Additional Insured:�Brixmor HTG SPE 5 LLC
CERTIFICATE-HOLDER CANCECLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE 'EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Brixmoi HTGSPE 5 LLC ACCORDANCE WITH THE.POLICY PROVISIONS.
420 Lexingron Ave, 7th Floor
New York NY 10170 AIITHORI2ED REPRESENTATIVE
���
OO�1988-2010 ACORD CORPORA710N. All rights reserved.
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD
Q�+EHi Of NOyf1
=a Indiana Department of Homeland Security (IDHS)
_ ` Division of Fire and Building Safety
Certificate of Compliance for Retail Sale of Consumer Fireworks (as defned in iC 22-i�-ia-�)
Certifica�eNumber: � Year � .-
1 _ +a n +r �.�, � � s
FWT25923 i¢ �` °tl�' 'n , � �+1,"'R' nP �����2014�f�s��M4�y°`'i���Y`� �k�i�W:���
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'"� � � c a�. A ��ri��s...7r�� '-a.
s�.�.� �.'�d..,..,a'€ � @ Y" (��, s'
Retail Type: �t,i ti, y ' � �' #4 �7 r �
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ti �9'J('��rFirlwrl�����e'"���5c$ a.,�, �' !��y,� ts.t�.; �.�'� �d' �:4
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Pursuant to IC 22-11-14-5 this'Certificate"of,Compliance';for Reta�l Sale of Consumer Fireworks is issued to
� � •,�.. � �,� � � � ; s
the applicant listed below; � °"' "— -- +nn '�r �,t � i
, i j�F"'�� �+F aa a�.s}�i � �i� r��4� u �rt���I
w . � � ���T" a�*-�' � � ��4� .�
USA HALLOWEEN PLANET.�INC ° r y a ,�' F �� � �_ "
t . # 5�#`it"-.-� _�� M^�r.' ��� f �, urc,�1 ,�nh"`�;-'..a s((F�� ..k t�r � � � .
13664NMERIDIANSTr���� � . � � ' � ;; ��� "�y�'� "yy �� � � ��„
CARMEL, IN 46032 n�e ri ,�+a%'� '�"� " � �� `` �� } ��, "
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This Certificate of Compliance forRetail Sale of Consumer Fveworks expires,on December 31, 2014
t �ra��I��� ��i,,"�e�W o4 +H��u�}k�. ri}`����r��'�`���'"�i�L��r �TM�a��' � �l,,,y k��m �
This Certi£cate�of Compliance for�Retail Sale of Consumer Firewo�ks is not transferable�except to a
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subsequent owner or operator of a fireworks business at;the above location in accordance with the policies and
,rt �� ;
guidelines of the�State Fire Marshal. �"�` �e � � ����
� .� �',.., '`� ::"' : u�.,.
This Certificate of Compliance for Re ail Sale of C nsumer Fve orks is vahd4only for a:tent or a structure at
d✓" I la
the address listed above.A'separate Certiflwte of Compliance'for Retail Sele of'Consumer Fireworks shall
d �, �
be obtained for each tent or structu`re'in which co'nsumer`fireworks are�sofd �- ��'�� �� ,
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� ry.cif�,:=�_ .at .r ,.'k.e "Y�.. .r� .—�e-=._d ,..—,.�""s.: ......_�m ..,�.„ �
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James L Greeson,.;lndiana Slate�File Marshal y,..�r�w��,...�� ,f`� Rk;�� Date„�`���'"}rf����. ,�s�,;� � ,1 , ,,, ,..I , ,a�{� �
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USA HALLOWEEN PLANET INC
7800 RECORDS ST
SUITE A
INDIANAPOLIS, IN 46226 (page 1 of 1)