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Francine R. Digitally signed by FrancineR. <br />Villareal <br />V i I I a rPa I Date: 2021.04.05 13:10:56-07'00' <br />ACORD® CERTIFICATE OF LIABILITY INSURANCE <br />DAT/ <br />03/17/17/2021 Y' <br />021 <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 INSUREDS), 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 />A//C,NNo, Ext : 1-800-648-6406 FAX <br />No)- 1-260-459-5940 <br />E-MAIL <br />ADDRESS: info@martialartsinsurance-kk.com <br />PRODUCER <br />CUSTOMER ID: <br />INSURER(S) AFFORDING COVERAGE <br />NAIC # <br />INSURED 2001198409 CP# 34 <br />Martin Torres <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 />INSURER E: <br />INSURER F: <br />COVERAGES CERTIFICATE NUMBER: 2000496677 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/DD/YYYY) <br />POLICY EXP <br />(MM/DD/YYYY) <br />LIMITS <br />A <br />X <br />COMMERCIAL GENERAL LIABILITY <br />X <br />6BRPG0000007445900 <br />04/01/21 <br />04/01/22 <br />EACH OCCURRENCE <br />$1,000,000 <br />CLAIMS -MADE � OCCUR <br />12:01 AM <br />12:01 AM <br />DAMAGE TO RENTED <br />PREMISES Ea Occurrence <br />$1,000,000 <br />VIED EXP (Any one person) <br />$5,000 <br />PERSONAL & ADV INJURY <br />$1,000,000 <br />GEN'L AGGREGATE LIMIT APPLIES PER: <br />GENERAL AGGREGATE <br />$5,000,000 <br />POLICY ❑ PROJECT ❑ LOC <br />PRODUCTS — COMP/OP AGG <br />$1,000,000 <br />PROFESSIONAL LIABILITY <br />$1,000,000 <br />OTHER: <br />LEGAL LIAB TO PARTICIPANTS <br />$1,000,000 <br />AUTOMOBILE LIABILITY <br />COMBINED SINGLE LIMIT (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 />PROPERTY DAMAGE <br />AUTOS ONLY AUTOS ONLY <br />Per accident <br />X Not provided while in Hawaii <br />UMBRELLA OCCUR <br />LIAB <br />EACH OCCURRENCE <br />AGGREGATE <br />EXCESS LIAB CLAIMS -MADE <br />DED F RETENTION <br />WORKERS COMPENSATION <br />AND EMPLOYERS' LIABILITY <br />N/A <br />PER STATUTE OTHER <br />ANY PROPRIETOR/PARTNER/ Y / N <br />E.L. EACH ACCIDENT <br />EXECUTIVE OFFICER/MEMBER <br />EXCLUDED? (Mandatory in NH) <br />E.L. DISEASE — EA EMPLOYEE <br />If yes, describe under <br />DESCRIPTION OF OPERATIONS below <br />E.L. DISEASE — POLICY LIMIT <br />MEDICAL PAYMENTS FOR PARTICIPANTS <br />PRIMARY MEDICAL <br />EXCESS MEDICAL <br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) <br />RE: Martial Arts Instructor <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 #2000496398 <br />CERTIFICATE HOLDER CANCELLATION <br />City of Santa Ana Risk Management Division <br />20 Civic Center Plaza <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE <br />EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH <br />Santa Ana, CA 92701 <br />THE POLICY PROVISIONS. <br />Owner/Manager/Lessor of Premises <br />AUTHORIZED REPRESENTATIVE <br />(01988-2015 ACORD CORPORATION. All rights 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 an <br />ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD <br />�oRaN <br />RiskMomigernentDMsian <br />REVIEWED & APPROVED BY. - <br />Risk Management Analyst <br />