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____"0M0N <br />14r—"KU GLF{ I ItIGA I L OF LIABILITY INSURANCE <br />DATE(MMIDDNYYY) <br />02/03/2020 <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 INSURERS), AUTHORIZED <br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. <br />IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed, <br />If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, 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 />g Y <br />Fort Wayne IN 46804 <br />CONTACT NAME: Mass Merchandising <br />P ONE 1-800-648-6406 FAx 1-260-459-5940 <br />u c, No Ext : ac No <br />E-MAIL info@danceinsurance-kk.com <br />ADDRESS: <br />PRODUCER <br />CUSTOMER to, <br />INSURER(S) AFFORDING COVERAGE <br />NAIC N <br />INSURED 2000942407 CP# 192 <br />Karina Morales Ocampo <br />9772 Santiago Blvd. <br />Villa Park, CA 92867 <br />A Member of the Sports, Leisure & Entertainment RPG <br />INSURER A: Nationwide Mutual Insurance Company <br />25787 <br />INSURER B: <br />INSURER C: <br />INSURER D: <br />INSURER E: <br />NSURER F: <br />COVERAGES CERTIFICATE NUMBER: 2000456819 DClrletnki en aaoCo. <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 BV PAID CLAIMS. <br />INSR <br />I-THMM/00/Y <br />TYPE OF INSURANCE <br />ADO <br />SUBR WVD <br />POLICY NUMBER <br />POLICY EFF <br />POLICY EXP <br />MM/DD/YYYY <br />LIMITS <br />A <br />X <br />COMMERCIAL GENERAL LIABILITY <br />CLAIMS -MADE X OCCUR <br />X <br />6BRPG000O007214200 <br />01/18/20 <br />12:01 AM <br />01/18/21 <br />12:01 AM <br />EACH OCCURRENCE <br />$1,000,000 <br />pAMAGE TO RENTED <br />PREMISES ILa Occurrence <br />$1,000,000 <br />MED EXP (Any one person) <br />$5,000 <br />PERSONAL&ADV INJURY <br />$1,000,000 <br />GEN'L AGGREGATE LIMIT APPLIES PER: <br />POLICY PROJECT ❑ LOG <br />GENERAL AGGREGATE <br />$5,000,000 <br />PRODUCTS—COMP/OP AGO <br />$1,000,000 <br />OTHER: <br />PROFESSIONAL LIABIUTY <br />$1,000,000 <br />LEGAL LIAB TO PARTICIPANTS <br />$1,000,000 <br />AUTOMOBILE <br />LIABILITY <br />COMBINED SINGLE LIMIT (Ea <br />accident <br />ANY AUTO <br />OWNED SCHEDULED <br />BODILY INJURY (Per person) <br />BODILY INJURY (Per acdtlen[) <br />AUTOS ONLY AUTOS <br />HIRED NON -OWNED <br />AUTOS ONLY AUTOS ONLY <br />B <br />PROPERTY DAMAGE <br />per accident <br />X <br />Not provided while in Hawaii <br />UMBRELLA OCCUR <br />LIAB <br />EACH OCCURRENCE <br />EXCESS LIAR CLAIMS -MADE <br />AGGREGATE <br />DED RETENTION <br />WORKERS COMPENSATION <br />AND EMPLOYERS' LIABILITY <br />N/A <br />PERSTATUTE OTHER <br />ANY PROPRIETOR/PARTNER/ YIN <br />EXECUTIVE OFFICEtory In ER ❑ <br />EXCLUDED? (MarMatory in NH) <br />If yes, describe under <br />E.L. EACH ACCIDENT <br />E.L. DISEASE —EA EMPLOYEE <br />E.L. DISEASE —POLICY LIMIT <br />DESCRIPTION OF OPERATIONS below <br />MEDICAL PAYMENTS FOR PARTICIPANTS <br />PRIMARY MEDICAL <br />EXCESS MEDICAL <br />DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached it more space is required) <br />Non -Certified Instructor of: Ballet, Hip hop <br />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. <br />The general liability policy is primary, subject to the policy terms and conditions, as per form CG 00 01 <br />City of Santa Ana, its officers, agents, employees and volunteers <br />Risk Management Division <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE <br />20 Civic Center Drive. <br />EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH <br />OLICY PROVISIONS. <br />Santa Ana, CA 92702 <br />REVIEWED & APPRAMff <br />REPRESENTATIVE <br />Owner/Manager/Lessor of Premises <br />RISC MANAGEMENT Dflill <br />By <br />�ORRRED <br />u° 19e3-2015 ACORD CORPORATION. All rights reserved. <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 />