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ACORO® CERTIFICATE OF LIABILITY INSURANCE DATE (MWDO YYYY 11/27/2019 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 INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the Certificate holder Is an ADDITIONAL INSURED, the r[icy les) 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. 1712 Magnavox Way Fort Wayne IN 46804 CONTACT NAME: Mass MerChantin A� Est):1-800-676406 AC.NI: 1-260-459-5940 E-MAIL ADDRESS: info@martialartsinsurance-kk.com PRODUCER CUSTOMER ID: INSURERS AFFORDING COVERAGE NAIC# INSURED 2001198409 CP# 260 Martin Tomes 2421 W. Edinger PMB #1239 Santa Ana, CA 92704 A Member of the Sports, Leisure & Entertainment RPG INSURER A: Nationwide Mutual Insurance Company 23787 INSURER B: INSURER C: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 2000449745 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 ADOL Mo SUER WVD POLICY NUMBER POLICY FFF MM'DDI POLICY END' MWGON LIMITS A X COMMERCIAL GENERAL LIABILITY CWMSMADE ❑X OCCUR X 6BRPG0000006940000 I 01/01/20 12:01 AM 01/01/21 12:01 AM I EACH OCCURRENCE $1,000,D00 ED PREMISES Ea Occvrmrce PREMISES $1,000,000 MEO EXP(AM ore parean) $5,000 PERSONAL&ADVINJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PROJECT LOC OTHER: P GENERAL AGGREGATE $5,0D0,000 PRODUCTS -COMPIOP AGG $1,OD0,000 PROFESSIONAL LIABILITY $1,000,00() FGM LIABTOPARTICIPANTS $1,000,000 AUTOMOBILE LIABILITY IANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NOWOWNED AUTOSONLV HAUTOSONLY X Not provided while in Hawaii COMMaouxerl BODILY INJURY (Per person) BODILY INJURY(PW aeademl PR PER DAMAGE Per acddent LIAR OCCUR EXCESS UAB CLAIMSMADE DELI RETENTION EACH OCCURRENCE AGGREGATE WORKERS COMPENSATION AND EMPLOYERSLIABILITY ANY PROPRIETORPARTNER' YIN EXECUTIVE OFFICERMEM BER EXCLUDED' (Vm4story In Nip F7 It yea, descr UM DESCRIPTION OF OPERATIONS below NIA PERSTATIJTE OTHER EL EACH ACCIDENT EL DISEASE- EA EMPLOYEE E.L. DISEASE- POLICY LIMIT MEDICAL PAYMENTS FOR PARTICIPANTS PRIMARY MEDICAL EXCESS MEDICAL DESCRIPTION OF OPERATIONS i LOCATIONS) VEHICLES (ACORD 101, Additlooal Rerns ,s Schedule, may W aaach If mwe space Is r uired) 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. Risk Management Division 20 Civic Center Plaza Santa Ana, CA 92701 Owner/Manager/Lessor of Premises 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 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 ACORD 25 (201 G/03) The ACORD name and logo are registered marks of ACORD & APPROVED CEMENT DIVISION 0610Aa State o xas. SAMANTHA M. LAMBERT