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ACORO® CERTIFICATE OF LIABILITY INSURANCE F DATE(MMIDDM'YY) <br />llh� 1 05/17/2018 <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 BELOW. <br />THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE <br />OR PRODUCER, AND THE CERTIFICATE HOLDER. <br />IMPORTAN the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If <br />SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this <br />certificate does not confer rights to the certificate holder in lieu of such endorsements . <br />PRODUCER <br />CONTACT NAME: Mass Merchandising Underwriting <br />K&K Insurance Group, Inc. <br />1712 Magnavox Way <br />Fort Wayne IN 46804 <br />ac No Exe: 1-800-648-6406 uc No: 1-260-459-5940 <br />ADDRESS: info@danceinsurance-kk.com <br />P <br />CUSTOMER 10: <br />INSURER(5) AFFORDING COVERAGE NAIC# <br />INSURED <br />INSURER A: Nationwide Mutual Insurance Company 23787 <br />Lisa Fraser Thistle Academy of Irish Dance <br />242 S. Crawford Canyon Road#38, #38 <br />Orange, CA 92869 <br />INSURER B: <br />INSURER C: <br />INSURER D: <br />A Member of the Sports, Leisure & Entertainment RPG <br />NSURER E: <br />12:01 AM EDT <br />NSURER F: <br />COVERAGES CERTIFICATE NUMBER: W01233099 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 INDICATED. <br />NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE <br />ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF <br />SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br />INSR <br />LTR <br />TYPE OF INSURANCE <br />DO <br />WoPOLICY <br />NUMBER <br />POLICY MMIDD EFF <br />FOLIC YYYY <br />LIMITS <br />A <br />X COMMERCIAL GENERAL LIABILITY <br />X <br />6BMAS0000GO6030500 <br />12/21/2017 <br />12/21/2018 <br />EACH OCCURRENCE $1,000,000 <br />CI -AIMS. OCCUR <br />MADE <br />12:01 AM EDT <br />12:01 AM <br />PREMISES Ea Occurrence $300,000 <br />MED EXP (Any one person) $5,000 <br />PERSONAL &ADV INJURY $1,000,000 <br />GENERALAGGREGATE $5,000,000 <br />GEN'L AGGREGATE LIMIT APPLIES PER. <br />PRODUCTS - COMP/OP AGG $1,000,000 <br />POLICY ❑ JECT F-1 LOG <br />PROFESSIONAL LIABILITY $1,000,000 <br />OTHER: <br />LEGAL LIAB TO PARTICIPANTS $1,000,000 <br />A <br />AUTOMOBILE <br />LIABILITY <br />ANY AUTO <br />6BMASC000OD6030500 <br />12/21/2017 <br />12:01 AM EDT <br />12/21/2018 <br />12:01 AM <br />GUMBINED SINGLE LIMIT $1,000,000 <br />(Ea am[dent) <br />BODILY INJURY (Per person) <br />1X <br />OWNED AUTOS SCHEDULED <br />ONLY AUTOS <br />BODILY INJURY (Per aoddent) <br />X` <br />HIRED NON -OWNED <br />AUTOS ONLY X AUTOS ONLY <br />Per accident <br />NOT PROVIDED WHILE IN HAWAII <br />UMBRELLA UPIBOCCUR <br />EACH OCCURRENCE <br />EXCESS LIAB CLAIMS -MADE <br />AGGLEqITE <br />DED F1 RETENTION <br />WORKERS COMPENSATION AND <br />EMPLOYERS' LIABILITY <br />N/A <br />PER' - HER <br />STATUTES ' <br />ANV PROPRIETOR/PARTNEW YIN <br />E.L EfCH ACCIDE <br />EXECUTIVE OFFICERIMEMBER ❑ <br />EXCLUDED? (Mandatory In NH) <br />E.LD EA EM LOVEE <br />Ifyes, describe under DESCRIPTION <br />OF OPERATIONS below <br />°-r <br />E.L DI EASE MIT <br />A <br />MEDICAL PAYMENTS FOR PARTICIPANTS <br />6BMAS0000006030500 <br />12/21/ <br />1 <br />YM <br />,2:01 A <br />E <br />.0, <br />AL r $25,000 <br />DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, ma chetl if#Bb ' e r¢pyi'C00 <br />Location #1: The Dance Centre, 1899 N. Tustin Ave., Orange, California 92865 V c �K�' <br />Dance style(s): Irish �G 7 <br />The certificate holder is added as an additional insured, but only for liability Caused, in whole or ir6pdrt, by the acts or omissions of the named insured. <br />CERTIFICATE HOLDER CANCELLATION <br />City of Santa Ana <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />20 Civic Center Plaza, PO Box 1988 <br />Santa Ana, CA 92702 <br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />AUTHORIZED REPRESENTATIVE <br />(Owner/Lessor of Premises) <br />Coverage is only extended to U.S. events and aclivibes. <br />" NOTICE TO TEXAS INSUREDS: The Insurer for the Purchasing group may not be subject to all the insurance laws and regulations of the State of Texas <br />ACORD 25 (2016/03) @ 1988-2015 ACORD CORPORATION. All rights reserved. <br />The ACORD name and logo are registered marks of ACORD <br />