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ACvlz,o� CERTIFICATE OF LIABILITY INSURANCE
<br />DATE(MMIDD)YYYY)
<br />F09/03/2019
<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 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 />we No Ext: 1-800-506-4856 Na- 1-260-459-5590
<br />Emt
<br />ADDRESS: info@fitnessinsurance-kk.com
<br />PRODUCER
<br />CUSTOMER ID•
<br />INSURERS AFFORDING COVERAGE
<br />NAIC #
<br />INSURED 2001155757 CP# 1813
<br />Laverne Davis
<br />2221 S. Lowell Street
<br />Santa Ana, CA 92707
<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: 2000436808 REVISION NUMBER:
<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 BY PAID CLAIMS.
<br />INSR
<br />LTR
<br />TYPE OF INSURANCE
<br />ADDL
<br />INSD
<br />SUBR
<br />WVD
<br />POLICY NUMBER
<br />POLICY EFF
<br />MM/DDNYY
<br />POLICY EXP
<br />MM/DD1YYYY
<br />LIMITS
<br />A
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />X
<br />6BRPG0000006905300
<br />08/15/19
<br />08/15/21
<br />EACH OCCURRENCE
<br />$2,000,000
<br />CLAIMS -MADE [fl OCCUR
<br />12:17 PM EDT
<br />12:01 AM
<br />DAMAGETO RENTED
<br />PREMISES Ea Occurrence)$1,000,000
<br />MED EXP (Any one person)
<br />$10,000
<br />PERSONAL & ADV INJURY
<br />$2,000,000
<br />GEN'L AGGREGATE LIMIT APPLIES PER:
<br />GENERAL AGGREGATE
<br />per year $5,000,000
<br />POLICY n PROJECT ❑ LOC
<br />PRODUCTS-COMP/OP AGG
<br />per year $2,000,000
<br />PROFESSIONAL LIABILITY
<br />$2,000,000
<br />OTHER:
<br />LEGAL LIAB TO PARTICIPANTS
<br />$2,000,000
<br />AUTOMOBILE LIABILITY
<br />MINED SINGLE LIWIT—(Ea
<br />accident)
<br />BODILY INJURY (Per person)
<br />ANY AUTO
<br />OWNED SCHEDULED
<br />AUTOS ONLY AUTOS
<br />BODILY INJURY (Per accident)
<br />HIRED NON -OWNED
<br />AUTOS ONLY AUTOS ONLY
<br />e
<br />REVIEWED 8
<br />APPRO
<br />ED
<br />PROPERTY DAMAGE
<br />Peraccidenl
<br />X Not provided while in Hawaii
<br />LIAB OCCUR
<br />EACH OCCURRENCE
<br />AGGREGATE
<br />EXCESS LIAB CLAIMS -MADE
<br />SEP (t
<br />^019
<br />DED RETENTION
<br />0J
<br />4
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY
<br />ANY PROPRIETOWPARTNER/ Y/N
<br />ExECUTIVE OFFICER/MEMBER
<br />EXCLUDED? (Mandatory In NH)
<br />N/A
<br />FRANCINE R.
<br />AL
<br />PER STATUTE OTHER
<br />E.L. EACH ACCIDENT
<br />VILLAR
<br />E, L DISEASE - FA EMPLOYFF
<br />Ins , describe under
<br />DCRIPTION OF OPERATIONS below
<br />E.L. DISEASE- POLICY LIMIT
<br />A I
<br />MEDICAL PAYMENTS FOR PARTICIPANTS
<br />6BRPG0000006905300
<br />08/15/19
<br />12:17 PM EDT
<br />08/15/21
<br />12:01 AM
<br />PRIMARY MEDICAL
<br />EXCESS MEDICAL
<br />$5,000
<br />DESCRIPTION OF OPERA'iloNS / LOCATIONS 1 VEHICLES (ACORD 101, Addilionat Rnmorks Schedule, may be altsoimd if more space is required)
<br />Certified Instructor of: Children's fitness programs, ZUMBA®
<br />City of Santa Ana, Risk Management, its officers, employees, agents, representatives and volunteers are added as an additional insured, but only for liability
<br />caused, in whole or in part, by the acts or omissions of the named insured.
<br />Sexual Abuse or Sexual Molestation Liability - $100,000 Each Occurrence (included above)/ $300,000 Aggregate (included above)
<br />"'This certificate voids and replaces certificate A 2000434066—
<br />CERTIFICATE HOLDER CANCELLATION
<br />City of Santa 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, 4th Floor THE POLICY PROVISIONS.
<br />Santa Ana, CA 92702 AUTHORIZED REPRESENTATIVE
<br />Owner/Manager/Lessor of Premises
<br />019BB-2015 ACORD CORPORATION. All riahis 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 />
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