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ACORO' CERTIFICATE OF LIABILITY INSURANCE <br />DATE(MAVOOYYYY) <br />11/21/2019 <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(les) must have ADDITIONAL INSURED provisions or be endorsed. <br />If SUBROGATION IS WAIVED, subject to the terms and conditions of the po-Ilcy, certain policies may require an endorsement. A statement on <br />this certificate does not confer rights to the certificate holder In lieu of such endorsemenl(s). <br />PRODUCER <br />K&K Insurance Group, Inc. <br />1712 Magnavox Way <br />Fort Wayne IN 46804 <br />CONTACT NAME: Mass Merchandising_„_,,, <br />_ <br />1-800.648-6406 .1-260-459.6940 <br />Eel : AC No <br />EAMAIL <br />ADDRESS: Info@danceinsurance-kk.com <br />PRODUCER <br />CUSTOMER ID: <br />INSURE S AFFORDING COVERAGE <br />NAICa <br />INSURED 2001196285 CP# 1564 <br />Khai HOang <br />14401 Poplar Or <br />Tustin, CA 92780 <br />A Member of the Sports, Leisure 5 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: 20DO449239 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 />Was <br />LTR <br />TYPE OF INSURANCE <br />ADDL <br />TSO <br />�R <br />AVID <br />POLICY NUMBER <br />POLICY EFF <br />POLICY EXP <br />MM1VDMTY <br />LWR9 <br />A <br />X <br />COMMERCIAL GENERAL QABILITY <br />CUUMSMPOE X OCCUR <br />X <br />6BRP00000006933600 <br />01/01/20 <br />12:01 AM <br />12:01 AM" <br />EACH OCCURRENCE <br />$1,000.000 <br />DAMAGE TO RENTED <br />PREMISES E. Ocaurmxv <br />$1,000,000 <br />MED EXP A,y are Pr l <br />$5.000 <br />PERSONAL B ADV IWUBY <br />$1,000,000 <br />GI AGGREGATE LIMIT APPLIES PER: <br />GENERAL AGGREGATE <br />$5,000,000 <br />POLICY ❑PROJECT ❑LOC <br />PRODUCTS-COMP/OP AGO <br />$1,OW,000 <br />PROFESSIONAL LIABILITY <br />$1,000,D00 <br />OTHER: <br />LEGAL LIAR TO PARTICIPANTS <br />$1,000.000 <br />AUTOMOBILE <br />LIABILITY <br />CKWEIY 1 <br />ANY AUTO <br />BODILYINJURY(Per Pe ) <br />OWNED SCHEDULED <br />AUTOS ONLY AUTOS <br />BODILYINJURYIFeraaitlenll <br />HIRED NON -OWNED <br />F <br />PROPERTY DAMAGE <br />AUTOS ONLY AUTOS ONLY <br />Per atxk <br />X <br />Not provided while in Hawaii <br />LIAR OCCUR <br />EACHOCCURRENCE <br />AGGREGATE <br />EXCESS UAS CLAIM -MADE <br />DEO RETENTION <br />WORKERS COMPENSATION <br />AND EMPLOYERS' LIABILITY <br />N/A <br />PER STATUTE OTHER <br />ANY FROPRIETORPARTNER YIN <br />EXECUTIVE OFFICEWMEMBER <br />E.L. EACH ACCIDENT <br />E.L. DISEASE - EA EMPLOYEE <br />EXCLUDED' M..&wry In NH) <br />II deecriea UAear <br />DEESCSCRIPTION OF OPERAnONS Oelpw <br />E.L. DISEASE - POLICY LIMIT <br />MEDICAL PAYMENTS FOR PARTICIPANTS <br />PRIMARY MEDICAL <br />EXCESS MEDICAL <br />DESCRIPTION OF OPERATIONS I LOCATIONS) VEHICLES (ACOR0101, Addift.1 Remart$ SCN Ule, my Oe enached it more $pace le r Ulmd) <br />Non -certified Instructor of: Ballroom, Square <br />City of Santa Ana, its officers, agents, employees, and volunteers are added as an additional insured, but only for liability caused, in whole or in part, by the <br />acts or omissions of the named insured. <br />This certificate voids and replaces certificate # W01630142, <br />CERTIFICATE HOLDER CANCELLATION <br />City of Santa Ana Risk Management <br />20 Civic Center Plaza & APPROVED <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE <br />REVIEWED <br />Santa Ana, CA 92701 �sRlSk <br />ANAGEMENT DIVISION <br />EXPIRATION DATE THEREOF, NOTICE WILL SE DELIVERED IN ACCORDANCE WITH <br />THE POLICY PROVISIONS. <br />Owner/Manager/Lessor of Prem <br />AUTHORIZED REPRESENTATIVE <br />27 201911 <br />/ <br />01988-2015 ACORD CORPORATION. All rights reserved. <br />� r <br />i <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 />