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ACORO® CERTIFICATE OF LIABILITY INSURANCE DATE(MWDDIYYYY) 12/23/2019 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 INSURERS), 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 KBK Insurance Group, Inc. 1712 Magnavox Way Fort Wayne IN 46804 CONTACT NAME: Mass Merchandising A,c No Ert, 1-800-648-6406 FAX N,, i-260-459-5940 EMAIL ADDRESS: info@marlialartsinsurance-kk.com PRODUCER CUSTOMER ID: INSURE S AFFORDING COVERAGE NAILS INSURED 2001205702 CP# 5 Joseph Pizarro 518 S Sullivan St. Sp 59 Santa Ana, CA 92703 A Member of the Sports, Leisure 8 Entertainment RPG INSURER A: Nationwide Mutual Insurance Company 23787 INSURER B: INSURER C: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 2000452512 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 SUBfl WVD POLICY NUMBER POLICY EFF MDDIYYY POLICY EXP MWDDIY LIMITS A X COMMERCIALGENERALUABILITY X 6BRPGOD00007213900 01/01/20 01/01/21 EACH OCCURRENCE $1,000,000 CLAIMSMAOE OCCUR 12:01 AM 12:01 AM PREMISES Ea RENTED ES( RENTED PREMISESwe $I DD0,0D0 MED EXP(Any one person) $5,000 PERSONAL a AOV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $5,000,000 POLICY PROJECT LOD PRODUCTS-COMPAOP AGG $1,OGO,000 PROFESSIONAL LIABILITY $1,000,000 OTHER: LEGAL UAB TO PARTICIPANTS $1,000,000 AUTOMOBILE LIABILITY CONISINED arcldenl BODILY INJURY (Par Person)) AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY lowactldeN) HIRED NON -OWNED PERTY PRODAMAGE AUTOS ONLY AUTOS ONLY Per aD;i0m1 XI X Not provided while in Hawaii UAS OCCUR EACH OCCURRENCE AGGREGATE EXCESS UAB CLAIMS -MADE DED RETENTION WORKERS COMPENSATION AND EMPLOYERS' LIABILITY N/A PERSTATUTE OTHER ANY PROPRIETORPARTNER Y / N EXECUTIVE OFFICER MENBER EXCLUDED9 (NeMatory in NH) E.L EACH ACCIDENT E.L DISEASE -EA EMPLOYEE If yA6, deg w urger DESCRIPTION OF OPERATIONS below E.L DISEASE -POLICY LIMIT MEDICAL PAYMENTS FOR PARTICIPANTS PRIMARY MEDICAL EXCESS MEDICAL DESCRIPTION OF OPERATIONS LOCATIONS I VEHKILES (ACORD 101, Addillooal Remarks Schedule, may W allaclleU It more space Ie required) RE: Martial Arts Instructor The certificate holder is added as an additional insured, but only for liability caused, in whole or in part, by the acts or omissions of the named insured. [N�:illy[N_\i4 City of Santa Ana Risk Management Division 20 Civic Center Plaza Santa Ana, CA 92701 Owner/Manager/Lessor of & APPROVED u•.vNi DIVISION 132020 M.LAMBERT 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 lx� Coverage is only extended to U.S. events and activities. 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. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD