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Oct 21 04 11:51a FITNESS and WELLNESS 8585190822 p.2 <br />f SANTA ANA RISK MGMT. Fax:714-647-5311 I Oct 14 2004 16:58 P.02 <br />ACCRD CERTIFICATE OF LIABIL[ <br />'��- <br />INSURANCE OATE(MMfbOIYYYY) <br />0912?J2004 <br />PRODUCER <br />FITNESS AND WELLNESS INSURANCE AGENCY <br />380 STEMS AVENUE, SURE 206 <br />THIS CERTIFICATE IS ISSUED AS A MATTER OF WFORMATION <br />ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE <br />HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR <br />SOLANA BEACH CA 92075 <br />Apency LicM OD28716 <br />RS AFFORDING COVERAGE <br />NAIC # <br />INSURED Al ,per/ <br />A. HIGUERA N ' QM 3—oI <br />CIO KARATE DO 019NAWA501 N COMMONWEALTH AVE. /- dW3— d L77-61 <br />A: Zurich American hisumn40 CompanJORGE <br />jUR <br />B: <br />C: <br />4 <br />INSUR <br />R E: <br />FULLERTON CA 92031 <br />THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NA <br />IED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING <br />ANY REQUIREMWT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT W <br />ni RESPECT Ta WHICH THIS CeRnFICATE MAY BE ISSUED OR <br />MAY P-RTAIk THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUI <br />JGCT TO ALLTHE TERNS, EXCLUSIONS AND CONDITIONS OF SUCH <br />POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br />NSR <br />ADM <br />TYPE OF INSURANCE <br />POLICY NUMBER <br />%U <br />FFIE � <br />1104 <br />POLICY EXPMATION <br />UNITS <br />EN LLIABILrrY <br />E01-9012327-00 <br />101 <br />10R1/05 <br />EACH OCCURR MM <br />$ 1.000,000 <br />0WOETUFAWIEt] <br />3 100,000 <br />LRL GENERAL LVAILI <br />LOLA'IM6MADEE OCCUR <br />MED. EXP (Any am person) <br />3 2,500 <br />A <br />PERSONALBADVNLIURY <br />3 1000000 <br />GEN16RALAGGREGATE <br />S 3%W000 <br />GENL AGGREGATE UMrrAPPLIFS PER <br />PRODUCTSCOMFJOP AGG. <br />S 3,000,000 <br />x POLICYLjowam El Loc <br />AUTOMOBILE LIABILITY <br />ANYAUTO <br />COMBINED SINGLE uMIT <br />(EA accident) <br />$ <br />ALL OPINED AUTOS <br />BODILY INJURY <br />SCHEDULEDAUTOS <br />(Per person) <br />3 <br />HIRED AUTOS <br />NON -OWNED AUTOS <br />BODILY INJURY <br />(Pcr,apcidwO <br />3 <br />PROPERTY DAMAGR <br />S <br />Per awftnt <br />GARAGE LIABILITY <br />All'TOONLY-EAAOCIOENT <br />9 <br />OTHOZTHAN EA ACC <br />3 <br />ANYAUTO <br />AUPD ONLY: arn <br />EXCESS I UMBRELLA LIABILITY <br />OCCUR 0 CLAIMS MADE <br />EACH OCCURRENCE <br />S <br />AGGREGATE <br />S <br />i <br />DEDUCT)BLE <br />S <br />RETENTION $ <br />' <br />3 <br />WORKERS COMPENSATION AND <br />/ <br />rvc STt <br />D7L8Z <br />EMPLOYERS' LlARIUiY <br />` <br />EL.EACNACCIDENT <br />E <br />ANY P ARTMERIEX UnVE <br />E.L. DISEASE -EA EMPLOYEE <br />E <br />OFFICERIMEMBER EXCLUOED9 <br />Myer, l — it r u Clw <br />E-L. DISEASE4MUCY UA4T <br />S <br />SPECIAL PROMONB War <br />OTHER: <br />DESCRIPTION OF OPERA-IONSILOCATIONSNMICLFS=CLUSIONS ADDED <br />BY ENDORSEMENT/ SPECIAL PROVISIONS <br />CERTIFICATE HOLDER ADDED AS ADDMONAL INSURED ONLYAS THFIF <br />INTERESTS MAY APPEAR. <br />LD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORETHE <br />1RATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 <br />The City of Santa Ana <br />FA <br />WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.BUY <br />LURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE <br />20 Civic Center Plaid <br />IN <br />UREK D'S AGENTS OR REPRESENTATIVES. <br />Santa Ana CA 92701 <br />AL <br />RZEDREPRESENTATIVE <br />Attention: <br />Ryan T n, nt Execuiivo <br />AGrJXQ Z5 (21DOII08) CBrtlfimft # 8515 1 UIJZbf TO W AUUKU ULMK UKAI fUN lVW <br />