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ACORO CERTIFICATE OF LIABILITY INSURANCE <br />DATE(MM/DD/YYYY) <br />11/07/2019 <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 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 />Fort Wayne IN 46804 <br />CONTACT NAME: Mass Merchandising <br />PHONE 1-800-426-2889 Fax 1-260-459-5105 <br />ac No <br />E <br />MAIL°r <br />ADDRESS: info@sportsinsurance-kk.com <br />PRODUCER <br />CUSTOMER ID: <br />INSURERS AFFORDING COVERAGE <br />NAIC If <br />INSURED 2001191574 CP# 2191 <br />Arlene Ruffin <br />28 Grant <br />]wine, CA 92620 <br />A Member of the Sports, Leisure & Entertainment RPG <br />INSURER A: Nationwide Mutual Insurance Company <br />23787 <br />INSURER B: <br />INSURER C: <br />INSURER D: <br />INSURER E: <br />INSURER F: <br />COVERAGES CERTIFICATE NUMBER: 2000447546 RFVIAInM Nil laao FD. <br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TOTHE 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 />INSD <br />BUBR <br />WVD <br />POLICY NUMBER <br />POLICY EFF <br />MWDDNW <br />POLICY EXP <br />MM/DD/YYY <br />LIMITS <br />A <br />X <br />COMMERCIAL GENERAL LIABILITY <br />CLAIMSMADE X OCCUR <br />X <br />68RPG0000006932900 <br />01/01/20 <br />12:01 AM <br />01/01/21 <br />12:01 AM <br />EACH OCCURRENCE <br />$1,000,000 <br />pAN1AGE TO RENTED <br />PREMISES Ea Occuneece <br />$1,000,000 <br />MED EXP(My one person) <br />$5,000 <br />PERSONAL S ADV INJURYA$5,000,000 <br />GEN'L AGGREGATE LIMIT APPLIES PER: <br />❑ PROJECT LOC <br />GENERAL AGGREGATEPOLICY <br />PRODUCTS—COMP/OP AGOOTHER: <br />PROFESSIONAL LIABILITYLEGAL <br />LIAR TO PARTICIPANTS <br />AUTOMOBILE <br />LIABILITY <br />COMBINED SINGLE LIMIT (Ea <br />accitlent <br />AUTO <br />OWNED SCHEDULED <br />BODILY INJURY (Per person) <br />BODILY INJURY (Per accident) <br />IANY <br />AUTOS ONLY AUTOS <br />HIRED NON -OWNED <br />AUTOS ONLY AUTOS ONLY <br />PROPERTY DAMAGE <br />Per accident <br />X <br />Not provided while in Hawaii <br />UMBRELLA OCCUR <br />LIAR <br />EACH OCCURRENCE <br />EXCESS LIAR CLAIMS -MADE <br />AGGREGATE <br />11 <br />DED RETENTION <br />WORKERS COMPENSATION <br />AND EMPLOYERS' LIABILITY <br />N/A <br />PER STATIITE OTHER <br />ANY PROPRIETOR/PARTNEW YIN <br />EXECUTIVE OFFICER/MEMBER ❑ <br />EXCLUDED? (Mandatory 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 if more space is required) <br />Instructor of: Tennis <br />Sports instruction conducted at locations that are NOT owned or operated by the 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 />" This certificate replaces certificate #WO1622111 effective '01/01/20' <br />irrc . I. nvwr=n GANuicLLA I IUN <br />City Of Santa Ana <br />20 Civic Center Plaza <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE <br />Plaza, CA 92701 <br />EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH <br />Owner/Manager/Lessor PremiREVIEWED & APPROVED <br />THE POLICY PROVISIONS. <br />of <br />DIVISION <br />BY RISC MANAGEMENTAUTHORIZED <br />REPRESENTATIVE <br />-X � / <br />dt� U 1988-2015 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 />