Laserfiche WebLink
DATE (MM/DD/Y ) <br />ACORDTM CERTIFICATE OF LIABILITY INSURANCE 11107/2011 <br />HIS 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 />HIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZE <br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. <br />IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the <br />arms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the <br />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 />PHONE (A/C, No. Eat): 1-800-506-4856 IFAX (A/C, No): 1-260-459-5590 <br />E-MAIL ADDRESS: InfoQfltnessinsumnCe-kk. CAT <br />PRODUCER CUSTOMER ID #: 2000037525 <br />NSURED CP# 4290 <br />Janet Farias Coca -Garcia <br />1228 S.Sycamore St <br />anta Ana, CA 92707 <br />Member of the Sports, Leisure & Entertainment RPG <br />INSURER(S) AFFORDING COVERAGE NAIC # <br />INSURER A: Nationwide Mutual Insurance Company 23787 <br />INSURER B: <br />INSURER C: <br />INSURER D: <br />COVERAGES CERTIFICATE NUMBER: 2000033807 REVISION NUMBER: <br />HIS 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 />UCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br />INSR <br />LTR <br />TYPE OF INSURANCE <br />ADDL <br />INSR <br />SUER <br />WVD <br />POLICY NUMBER <br />POLICY EFF <br />MM/DD <br />POLICY EXP <br />MWDD/W <br />LIMITS <br />A <br />GENERAL LIABILITY <br />Owner/Mena er/LessLessor of Premises <br />6BRPG0000004934600 <br />11/02/11 <br />11/02/12 <br />EACH OCCURRENCE $1,000,000 <br />X COMMERCIAL GENERAL LIABILITY <br />1201 AM <br />12:01 AM <br />DAMAGE TO RENTED <br />PREMISES Ea occurrence $500,000 <br />CLAIMS -MADE FX ] OCCUR <br />MED EXP (Any one person) $10,000 <br />PERSONAL B ADV INJURY $1,000,000 <br />GENERAL AGGREGATE $3'000,000 <br />GEN -L AGGREGATE LIMIT APPLIES PER: <br />PRODUCTS-COMP/OP AGG $1.000,000 <br />POLICY =PROJECT= LOC <br />PROFESSIONAL LIABILITY $1,000,000 <br />LEGAL LIAB TO PARTICIPANTS $1,000,000 <br />AUTOMOBILE LIABILITY <br />COMBINED SINGLE LIMIT <br />Ea Accident <br />BODILY INJURY (Per person) <br />ANY AUTO <br />BODILY INJURY (P.—id-1) <br />ALL OWNED AUTOSA <br />SCHEDULED AUTOS <br />HIRED AUTOS <br />NON -OWNED AUTOS <br />X Not provided while in Hawaii <br />c� <br />alt-ll-Paor <br />Yo1Zl�A <br />acrJtlen DAMAGE <br />UMBRELLA LIAR <br />OCCUR <br />y/ �( �Ia C", "I <br />EACH OCCURRENCE <br />AGGREGATE <br />EXCESS LIAB <br />CLAIMS-MADEa_.��'t�I <br />, <br />r`ti1C�2r <br />DEDUCTIBLE <br />RETENTION <br />WORKERS COMPENSATION <br />WC STA TU- OTH- <br />I <br />AND EMPLOYERS' LIABILITY YIN <br />TORY LIMITS ER <br />ANY PROPRIETOWPARTNER/ <br />EXECUTIVE OFFICER/MEMBER <br />EXCLUDED' <br />N / A <br />E. L- EACH ACCIDENT <br />E.L. DISEASE - EA EMPLOYEE <br />(Mandatory In NH) <br />EL DISEASE- POLICY LIMIT <br />If yes, descno. untler <br />DESCRIPTION OF OPERATIONS below <br />MEDICAL PAYMENTS FOR <br />PRIMARY MEDICAL <br />PARTICIPANTS <br />EXCESS MEDICAL <br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional R—M, Schedule, If more space Is required) <br />Certified Instructor of: Dance, ZUMBA® <br />The certificate holder is added as an additional insured, but only with respect to the liability arising out of the operations of the insured named above. <br />"Voids and Re laces Certificate #WO0134198" <br />CERTIFICATE HOLDER CANCELLATION <br />City of Santa Ana, its Officers, agents and employees <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED <br />Parks, Recreation and Community Services Agency <br />BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />Attn: Carmen Acosta <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />1825 W. Civic Center <br />AUTHORIZED REPRESENTATIVE <br />Santa Ana, Cg 92701 <br />Owner/Mena er/LessLessor of Premises <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 (2009/09) © 1988-2009 ACORD CORPORATION. All rights reserved. <br />The ACORD name and logo are registered marks of ACORD <br />