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ACORO CERTIFICATE OF LIABILITY INSURANCE <br />DATE(MM/ODIYYYY) <br />02/12/2020 <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 INSURER(S), AUTHORIZED <br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. <br />IMPORTANT: It the certificate holder is an ADDITIONAL INSURED, the pollcysies) must have ADDITIONAL INSURED provisions or be endorsed. <br />If SUBROGATION IS WAIVED, subject to the terms and conditions of the pol 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 />K3K Insurance Group, Inc. <br />1712 Magnavox Way <br />Fort Wayne IN 46804 <br />CONTACT NAME: Mass MerChaOdising <br />FAX <br />AIc Na Emu i-600-648-8406QVC. No : 1 260-459-5940 <br />E.MIUL <br />ADDRESS: info@danceinsurence-kkcom <br />PRODUCER <br />CUSTOMER IO; <br />INSURER(S) AFFORDING COVERAGE <br />NAICA <br />INSURED 001219054 CP1t 251 <br />Raquel Gutierrez <br />3101 S. Fairview Stiff <br />Santa Ana, CA 92704 <br />A Member of the Sports, Leisure 8 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: 2000458303 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 />AOUL <br />B$D <br />SUBR <br />WVD <br />POLICY NUMBER <br />POLICY EFF <br />pOLX:YEXP <br />MMIDDN <br />LIMBS <br />A <br />X <br />COMMERCIAL GENERAL LIABILITY <br />CLUMSMADE ❑X OCCUR <br />X <br />6BRPG000OD07214200 <br />02/1020 <br />12:01 AM <br />02/1N21 <br />12V AM <br />EACHOCCURRENCE <br />$1,000,000 <br />DAMAGE TO RENTED <br />PREMISES EaCeemmxn <br />$1,0001000 <br />MED EXP(My one person) <br />$5,000 <br />PERSONAL A ADV INJURY <br />$1,000,000 <br />GEN'L AGGREGATE LIMIT APPLIES PER: <br />GENERAL AGGREGATE <br />$5,000,000 <br />POLICY ❑PROJECT 0 LOC <br />PRODUCTS -ODMPJOP AGG <br />$1,000,000 <br />OTHER. <br />PROFESSIONAL UABIUTY <br />$1,000,000 <br />LEGAL UAB TO PARTICIPANTS <br />$1,000,000 <br />AUTOMOBILE <br />LIABILITY <br />= Ea <br />AUTO <br />OWNED SGHEOUIED <br />AUTOS ONLY AUTOS <br />BODILY INIURY(Parparson) <br />BODILYMURYIPeracamao) <br />HIRED NON -OWNED <br />AUTOS ONLY AUTOS ONLY <br />PROPERTY DAMAGE <br />par makkal <br />XI <br />X <br />Not provided while in Hawaii <br />UMBRELLA <br />LAB OCCUR <br />EACH OCCURRENCE <br />EXCESS UAB CLAIMS -MADE <br />AGGREGATE <br />OED RETEMION <br />WORKERS COMPENSATION <br />AND EMPLOYERS' UABILnY <br />WA <br />PER $TAME OTHER <br />ANY PROPRIETORPARTNEW YIN <br />EXECUTIVE OFFICERNIEMBER <br />EXCLUDED? Mandarory In NHJ <br />EL. EACH ACCIDENT <br />EL DISEASE -EA EMPLOYEE <br />Ilyyeess desaiba under <br />DEGCRIPDON OF OPERADIXJB below <br />EL DISEASE -POLICY LIMB <br />MEDICAL PAYMENTS FOR PARTICIPANTS <br />PRIMARY MEDICAL <br />EXCESS MEDICAL <br />DESCRIPTION OF OPERATIONS I LOCATIONS i VEHICLES (ACORD 101, Atltlllbnal Remarks Schedule, may be atlachetl II more space b repuin±d) <br />Certified Instructor of: Zumba® <br />City of Santa Ana, its officers, agents, employees. aDtl volunteers are added as an additional insured, but only for liability Caused, in whole or in pad, by the <br />acts or omissions of the named insured. R <br />This certificate voids and replaces certificate If W01677331. <br />UCN I IFMHa I r NULULK CANCELLATION <br />City of Santa Ana <br />Risk Management Division <br />20 Civic Center Plaza J <br />Santa Ana, 92702 <br />Owner/Manager/Lessor <br />er/Lessor of Premises <br />REVIEWED&AIINMPROVISIONS. <br />By Risk MANACtEM <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE <br />DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH <br />ISLBNEPRESEMATIVE <br />-%� <br />""' 01988-2015 ACORD CORPORATION. All rights reserved. <br />ANC{IE ACEVEdo <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 (2016103) The ACORD name and logo are registered marks of ACORD <br />