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CERTIFICATE OF LIABILITY INSURANCE DATE IMMMDIY)fi 01 /01 /2024 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER JE2.%IACT Bene-Marc Athleti surance Agency #OEA789 Y°c , =.1 ( / I t o Inv 6301 Southwest u var�/Tgie ADDRty I a m I ADORe;; Fort Worth, Tex 2 INSURER S AFFO ING COVERAGE I NAIi INSUR' ' l: 11411 I I INSURED INSU OR B AXIS 1315tal Accident & Health Insurance Company Southern California Municipal Athletic Federation (SCMAF) PO Box 3605 INS ,RER C: Acevedo r_URF `,. South El Monte, 3 SCMAF MemberINSURER E: _ INSURER F: - • COVERAGES CERTIFICATE NUMBER' 9r8P j4470 Kvii iiiIll THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADOL SUER POUCYNUMSER POUCYEFF MMIDD/YYYY POLICY EXP IMMMDIYYYYi LIMITS X COMMERCIALGENERAL LIABILITY CLAIMS -MADE X❑ OCCUR 18LB6293 01/01/2024 01/01/2025 EACHOCCURRENCE $ 1,000,000.00 DA A T TED PREMISES Ea occurrence $ 100,000.00 MED EXP (Any one person) $ 5,000.00 PERSONAL B ADV INJURY $ 1,000,000.00 A X X Abuse & Molestation GEN'L X AGGREGATE LIMIT APPLIES PER POLICY❑ iE° ❑ LOG GENERAL AGGREGATE $ 5,000,000.00 1,000,000 OCC./2,000,000 Agg. PRODUCTS - COMP/OP AGG s 1,000,000.00 Participant Liability S 1,000,000.00 OTHER. AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident) S BODILY INJURY(Perperson) S ANY AUTO OWNED SCHEDAUTOSULED AUTOS ONLY BODILY INJURY (Per accident) S HIRED NON-0WNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE -Peraccideni S S UMBRELLALIAB OCCUR EACH OCCURRENCE S AGGREGATE 3 EXCESS UAB CLAIMS -MADE DED I I RETENTIONS 3 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANYPROPRIETORIPARTNERIEXECUTIVE ❑ OFFICERIMEMBEREXCLUDED9 NIA I PER OTF- STATUTE ER E.L. EACH ACCIDENT $ E.L. DISEASE -EA EMPLOYEE S (Mandatary In NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT S B Participant Accident Medical SRPO-50256-243 01/01/2024 01/01/2025 Deductible:$0.00 Limit:$5,000.00 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101. Additional Remarks Schedule, maybe attached if more space is required) This policy includes a blanket additional insured endorsement that provides additional insured status to the certificate holder perform CG 20260704. The General Liability policy contains Primary and Non ComribuWry working per endorsement E1tl02AJ-1112, The General Liability policy contains an endorsement for Waiver of Transfer of Rights of Recovery Against Others to Us per attached form CG 24 04 05 incity of Santa Ana entry, is officers. officials. agents and Its volunteers are additlanal insured. Coverage for SCMAF member approved activities for which a premium is paid and reported to the Company. SCMAF Member: Martin Torres - Karate Do Kiai Coverage is limited to the following activity dates: 01/15/24-03/31/24 City of Santa Ana Risk Management 20 Civic Center Plaza Santa Ana, CA 92701 AUTHORIZED REPRESENTATIVE Alisa Lynn Hall © 1988-2015 ACORD ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELPITRED IN ACCORDANCE WITH THE POLICY PRC Risk Mmuga adD[dded lYgw REVIEWm SAPPROV®B/Y: .. Aar ALWorC �'. ® Risk Managemen[Speealis[Of