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ACORO® CERTIFICATE OF LIABILITY INSURANCE <br />DATE(MLVDD/YYYY) <br />v16 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 policyy((ies) must have ADDITIONAL INSURED provisions or be endorsed. <br />If SUBROGATION IS WAIVED, subject to the terms and conditions of the poll cy, 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 />Foil Wayne IN 46804 <br />CONTACT NAME: Mass Me'chandlsln <br />FAX <br />AcNo, Exl : 1-800-648-6406 (AC,NI ; 1-260-459-5940 <br />EMAIL <br />ADDRESS: info@danceinsurance-kkGom <br />PRODUCER <br />CUSTOMER ID: <br />INSURERS AFFORDING COVERAGE <br />NAILE <br />INSURED 2001203543 CP# 11 <br />Yessica Campos <br />7082 Fenway Dr. Apt5 <br />Westminster. CA 92683 <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 O: <br />INSURER E: <br />INSURER F: <br />COVERAGES CERTIFICATE NUMBER: 2000451701 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 />a1SR <br />LTA <br />TYPE OF INSURANCE <br />ADDL <br />INSD <br />SUER <br />,VD <br />POLICY NUMBER <br />POLICY EFF <br />AYDDI <br />POLICY OP <br />MWDD/Y <br />LIMITS <br />A <br />X <br />COMMERCIAL GENERAL LIABILITY <br />X <br />6BRPGOOD0007214200 <br />01/01/20 <br />OV01/21 <br />EACHOOCURRENCE <br />$11000,000 <br />CLAIMSMADE ❑X OCCUR <br />12:01 AM <br />12:01 AM <br />DAMAGE TO RENTED <br />PREMISES Ea Olxuna,re <br />$1,000.000 <br />MED EXP(Any One Doran) <br />$5,000 <br />PERSONAL A ADV INJURY <br />$1,DDO,000 <br />GEN'L AGGREGATE LIMIT APPLIES PER: <br />GENERAL AGGREGATE <br />$5,D00,G00 <br />POLICY ❑ PROJECT LOC <br />PRODUCTS-COMP/OP AGG <br />$1,D00.000 <br />OTHER: <br />PROFESSIONAL UABILRY <br />$1,DOO.000 <br />LEGAL UPS TO PARTICIPANTS <br />$1.000.000 <br />AUTOMOBILE <br />LIABILITY <br />coRRI�denl <br />BODILY INJURY (Per peraI <br />AUTO <br />IANY <br />OWNED SCHEDULED <br />AUTOS ONLY AUTOS <br />BODILY INJURY ME, accieam) <br />HIRED NON-0WNED <br />PROPERTY DAMAGE <br />AUTOSONLY AUTOS ONLY <br />Per accmnt <br />X <br />Not provided while in Hawaii <br />LIAR OCCUR <br />EACH OCCURRENCE <br />AGGREGATE <br />EXCESS DAB CLAIMS -MADE <br />DEC PETENTION <br />WORKERS COMPENSATION <br />ANO EMPLOYERS' UASILITY <br />N/A <br />PER STATUTE OTHER <br />ANY PROPRIETORPARTNER/ YIN <br />EXECUTIVE OFFICERMEMBER <br />El- EACH ACCIDENT <br />El DISEASE -EA EMPLOYEE <br />EXCLUDED? (MandMory In NH) <br />It yea, tlettraie UMer <br />DESCRIPTION OF OPERATIONS below <br />EL DISEASE —POLICY UNIT <br />MEDICAL PAYMENTS FOR PARTICIPANTS <br />PRIMARY MEDICAL <br />EXCESS MEDICAL <br />OESCRIPTION OF OPERATIONS I LOCATIONS) VEHICLES (ACORD 101, A4dilionel Remarks Schedule, may be attaclmC it more Wien IS MI <br />Non -Certified Instructor of: Ballet, Folk Dancing <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 />The general liability policy is primary, subject to the policy terms and conditions, as per form CG 00 01. <br />This certificate voids and replaces certificate # W01650751. <br />CERTIFICATE HOLDER CANCELLATION <br />City of Santa Ana <br />Risk Management Division REVIE <br />ED & APPROVED <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE <br />EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH <br />20 CIVIC Center Plaza <br />Y RIS <br />ANAGEMENT DIVISIO <br />THE POLICY PROVISIONS. <br />AUTHORQED REPRESENTATIVE <br />Santa Ana, CA 92702 <br />Owner/Manager/Lessor of Premise <br />20 2019 <br />A;E*f /a"-� <br />019W2015 ACORD CORPORATION. All rights reserved. <br />SAMANTHA M. LAMBERT <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 />