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ACORO® CERTIFICATE OF LIABILITY INSURANCE <br />DATEtMWDDNYYY) <br />11/27/2019 <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), AUTHORRED <br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. <br />IMPORTANT: It the certificate holder Is an ADDITIONAL INSURED, the policyties) 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 />H&K Insurance Group, Inc. <br />1712 Magnavox Way <br />Fort Wayne IN 46804 <br />CONTACT NAME: Mass MerChandl5in <br />_ <br />,vc Eat: 1-800-648-6406 A,o Np; 1-260-059-5940 <br />E-MAIL <br />ADDRESS: infG@martialartsinsurance-kk.com <br />PRODUCER <br />CUSTOMER 10, <br />INSURERS AFFORDING COVERAGE <br />NAIC a <br />INSURED 2001198409 CPN 260 <br />Martin Tones <br />2421 W. Edinger PMB #1239 <br />Santa Ana, CA 92704 <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 />NSUREfl E : <br />PINSURER <br />F: <br />COVERAGES CERTIFICATE NUMBER: 2000449745 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 />WVO <br />POLICY NUMBER <br />POLICY EFF <br />MMDDIYYY <br />POLICY EXP <br />INK, NM <br />LIMBS <br />A <br />GENERAL LIABILITY <br />X <br />68RPG0D000D6940000 <br />01/0120 <br />01/01/21 <br />EACH OCCURRENCE <br />$1.000.000 <br />TMMMERCIAL <br />CLAIMSMAOE OCCUR <br />12:01 AM <br />12:01 AM <br />DAMAGET AEENTED <br />PREMISES We Ouundwe <br />$1,000,000 <br />MEDEXP(Anyone Parton) <br />$5,000 <br />PERSONAL A ADV INJURY <br />$1,000,D00 <br />GEN'L AGGREGATE LIMIT APPLIES PER. <br />GENERAL AGGREGATE <br />$5,000,000 <br />POLICY ❑ PROJECT ❑ LOC <br />PRODUCTS -COMP/ AGO <br />$1,000,000 <br />PROFESSIONAL LIABILITY <br />$1,000,000 <br />OTHER. <br />LEGAL LIAR TO PARTICIPANTS <br />$1,000,0011 <br />AUTOMOBILE <br />LIABILITY <br />COMBINED SINGLE L]WrW— <br />acx,ffe,Y) <br />AUTO <br />BODILY INJURY (P. person) <br />IANY <br />OWNED SCHEDULED <br />AUT050NLY AUTOS <br />BODILY INJURY(P. acnleo) <br />HIRED NON -OWNED <br />AUTOS ONLY AUTOS ONLY <br />PROPERTY DAMAGE <br />Per pccitlenl <br />X <br />Not provided while In Hawaii <br />UMBRELLA LIAS OCCUR <br />EACH OCCURRENCE <br />EXCESS UAB CLAIMS MACE <br />AGGREGATE <br />DIED RETENTION <br />WORKERS COMPENSATION <br />AND EMPLOYERS' LIABILITY <br />N/A <br />PER STATUTE OTHER <br />ANYPROPRIETORPARTNER YIN <br />EXECUTNE OFFICERMEMBER <br />E.L EACH ACCIDENT <br />E.L. DISEASE - EA EMPLOYEE <br />EXCLUDED? (Mandatory In NH) <br />If yes, deecnben0e ur <br />DESCRIPTION OF OPERATIONS below <br />EA- DISEASE - POLICY LIMIT <br />MEDICAL PAYMENTS FOR PARTICIPANTS <br />PRIMARY MEOICAL <br />EXCESS MEDICAL <br />DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remras Schedule, may be edaehad It mare apace Ie mpulmd) <br />RE: Martial Arts Instructor <br />The certificate holder Is added as an additional insured, but only for liability Caused. in whole or in part. by the acts or omissions of the named insured. <br />CERTIFICATE HOLDER CANCELLATION <br />City of Santa Ana <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE <br />Risk Management Division <br />EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH <br />20 Civic Center Plaza <br />THE POLICY PROVISIONS. <br />Santa Ana, CA 92701 <br />AUTHORIZED REPRESENTATIVE <br />Owner/Manager/Lessor of Premises <br />®1988-2015 ACORD <br />Coverage is only extended to U.S. events and activities. <br />" NOTICE TO TEXAS INSUREDS: The Insurer for the purchasing group may not be subject to all the insurance laws <br />ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD <br />All rights reserved. <br />$ APf3K)VEU <br />(fivitlf Divisj0% <br />06te xas. <br />SAMANTHA M. t� A- N� - <br />