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,I O iff CERTIFICATE OF LIABILITY INSURANCE <br />DnrE/11/2019 <br />111/2019 <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 <br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. <br />IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the golicy(ies) must have ADDITIONAL INSURED provisions or be endorsed. <br />If SUBROGATION IS WAIVED, subject to the terms and conditions of the poliicy, 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 <br />K&K Insurance Group, Inc. <br />1712 Magnavox Way <br />Fort Wayne IN 46804 <br />CONTACT NAME: Mass Merchandising <br />ac No Eat: 1-800-648-6406 me 1-260-459-5940 <br />E-MAIL <br />ADDRESS: irdo@marfialartsinsurance-kk.com <br />PRODUCER <br />CUSTOMER 10: <br />INSURE S AFFORDING COVERAGE <br />NAICX <br />INSURED 2001191968 CPA 251 <br />Kevin Dalrymple <br />5722-5 E Stillwater Ave <br />Orange, CA 92869 <br />A Member of the Sports, Leisure & Entertainment RPG <br />INSURER A: Nationwide Mutual Insurance Company <br />23787 <br />INSURER a: <br />INSURER C: <br />INSUflER D: <br />INSURER E: <br />INSURER F: <br />COVERAGES CERTIFICATE NUMBER: 2000447885 REVISION NUMBER: <br />THIS ISTO 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 />ADDL <br />MD <br />SUER <br />WVO <br />POLICY NUMBER <br />POLICY EFF <br />POLICY EXP <br />MWDDIYY <br />UMITS <br />A <br />X <br />COMMERCIALGENERAL LIABILITY <br />X <br />6BRPG0000006940000 <br />11/01/19 <br />11/01mo <br />EACH OCCURRENCE <br />$1,000,000 <br />CLAIMS -MADE ❑X OCCUR <br />12:01 AM <br />12:01 AM <br />DAMAGETORENTED <br />PREMISES Ea Oc mmoa <br />$1,000,000 <br />MED EXP(My one persw) <br />$5,D00 <br />PERSONAL &ADV INJURY <br />$1,000,000 <br />GENL AGGREGATE LIMIT APPLIES PER: <br />GENERAL AGGREGATE <br />$5,000,000 <br />POLICY PROJECT ❑ LOG <br />PRODUCTS-COMP+OPAGG <br />$1,0D0.000 <br />PROFESSIONAL LIABILITY <br />$1,000,000 <br />OTHER: <br />LEGAL UAa TO PARTICIPANTS <br />$1.000,000 <br />AUTOMOBILE <br />LIABILITY <br />amdeM <br />BODILY INJURY (Par person) <br />AUTO <br />OWNED SCHEDULED <br />AUTOS ONLY AUTOS <br />BODILY INJURY (Per acddenq <br />HIRED NON OWNED <br />PROPERTY DAMAGE <br />AUTOS ONLY AUTOS ONLY <br />Per awdont <br />XI <br />X <br />Not provided while in Hawaii <br />Uldl OCCUR <br />LAS <br />EACH OCCURRENCE <br />AGGREGATE <br />EXCESS UAB CLAIMS -MADE <br />DED RETEMION <br />WORKERS COMPENSATION <br />AND EMPLOYERS' LIABILITY <br />NIA <br />PER STATUTE OTHER <br />ANY PROPRIETOR�PARTNERr YIN <br />E.L EACH ACCIDENT <br />EXECUTIVE OFFICERIMEMBER <br />EXCLUDED?(MerMMory In NH) <br />E.L DISEASE -EA EMPLOYEE <br />E.L DISEASE -POLICY LIMB <br />If yea,tl rwuMer <br />DESCRIPTION OF OPERATIONS helow <br />MEDICAL PAYMENTS FOR PARTICIPANTS <br />PRIMARY MEDICAL <br />EXCESS MEDICAL <br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remiss Schedule, may be attached it more space is required) <br />RE: Martial Arts Instructor <br />City of Santa Ana, Officers, Agents, Employees, and Volunteers are added as an additional insured, but only for liability caused, in whole or in part, by the acts <br />or omissions of the named insured. <br />The general liability policy is primary, subject to the policy terms and conditions, as per form CIS 00 01 <br />Lary or 5ama Ana SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE <br />Risk Management Division EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH <br />20 Civic Center Plaza REVIEWED 81 APPROVEI THE POLICY PROVISIONS. <br />Santa Ana, CA 92702 B R� ANAGEMEM "IV' <br />Owner/Manager/Lessor of Premises y UTHORQEO REPRESENTATIVE <br />01988.2015 ACORD CORPORATION. All rights reserved. <br />SAMA HA M. LAMBERT <br />Coverage is only extended to U.S. events and activities. <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) The ACORD name and logo are registered marks of ACORD <br />