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AcoRDTM CERTIFICATE OF LIABILITY INSURANCE OATEIMMre0 ) <br />0312712013 HOLDER. <br />NLY <br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION O qND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. <br />THIS <br />CERTIFICATE DOES NOTAFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND ORALTER THE COVERAGE AFFORDED <br />BY THE POLICIES BELOW. <br />THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURERS), AUTHORIZED <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 />terms 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 endorsements . <br />PRODUCER <br />CONTACT <br />Mass March Underwriting <br />K &K Insurance Group, Inc. <br />PHONE: <br />1712 Magnavox Way <br />Fort Wayne Indiana %. Q/ O� 3 <br />a/D No. Erl : <br />888-580 -8041 FAX: (AC, Noy 260459.5995 <br />EDOaess: <br />infe pfitnessinsurance- kk,com <br />46804 v1 — <br />02 <br />INSURER(S)AFFORDING COVERAGE NAIO# <br />INSURED <br />INSURERAI <br />Nationwide Mutual Insurance Com an 23787 <br />Laura Lorraine Simon <br />Net RER B: <br />1227 E. 14TH STREET <br />INSURER C: <br />INSURER D: <br />SANTA ANA, CA 92701 <br />1 Ran E: <br />A Member of the Sports, Leisure & Entertainment RPG <br />INSURER F: <br />COVERAGE$ CERTIFICATE <br />NUMBER: W00287672 REVISION NUMBER: <br />IS TO CERTIFY THAT THE POLICIES OF INSURANCE <br />LISTED BELOW HAVE BEEN ISSUED TO THE <br />ITHIS <br />ANY REQUIREMENT, TERM OR CONDITION <br />INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. <br />OF ANY CONTRACT OR OTHER <br />ISSUED OR MAY <br />ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED <br />DOCUMENT WITH RESPECT TO WHICH THIS CERTIPICATB MAY BE <br />BY THE POLICIES DESCRIBED HEREIN <br />SUCH POLICIES. LIMITS SHOWN MAY HAVE SEEN REDUCED <br />IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF <br />BY PAID CLAIMS, <br />NS TYPEOF INSURANCE ADDL SUER <br />LTR INSR WVD <br />POLICY NUMBER POLICY EFF POLICY EXP <br />A GENERAL LIgBILITY X <br />MMIDO MMIDDM/ LIMITS <br />BBRPG0000005342300 0:1 i 21713 03/27 /2p14 <br />X COMMERCIAL GENERAL LIABILITY <br />EACH OCCURRENCE $1,000,00 <br />5:30 PM EDT 12:01 AM DAMAGE TO RENTED <br />CLAIMS -MADE X�OCCUR <br />$500,000 <br />PREMISES F.re ence <br />MED EXP Any one person) $10,000 <br />PERSONAL& AOV ]NJ URY $1,000,000 <br />GENERALAOGREGATE <br />$5,000,00 <br />GEN'L AGGREGATE LIMIT APPLIES PER', <br />POLICY ❑PROJECT ❑LOC <br />PRODUCTS - COMP /OPAGG <br />$1000000 <br />PROFESSIONAL LIABILITY $1,000,00 <br />LEGAL LIAB TO PARTICIPANTS $1,000,00 <br />AUTOMOBILE LIABILITY <br />COMBINED SINGLE LIMIT <br />NY AUTO <br />Me Accident <br />LL OWNED AUTOS �SCHEDULEp <br />BODILY INJURY (Per person) <br />Not <br />BODILY INJURY (Paraccltlent) <br />-O NEO <br />IRED AUTOS NON-OWNED <br />I'�-- <br />UTOa <br />PROPERTY DAMAGE <br />..IyN`ON <br />providetl wbpe In Hawaii <br />Per acci0ent <br />UMBRELLA LIAB I JOCCUR <br />EXCESS LIAB CLAIMSMADE <br />EACH OCCURRENCE <br />AGGREGATE <br />DED RETENTION <br />WOR MPENBA <br />ANY UMPLOY ERS'LIARILIT Y YIN <br />STATU- OTHER <br />ANY <br />To <br />TORY LIMIT$ <br />EXECUTIVE UTIVE FFICERMENRTNER/ <br />EXCLUDED OFFICERJMEMBER <br />EXCLUDED? D9 N/A <br />E.L. EACH ACCIDENT <br />E.L. DISEASE — EA EMPLOYEE <br />(Mandan) In NH) <br />byes, <br />IP71Oeantler <br />below <br />E.L. 015FASE— POLICY LIMIT <br />MEDICAL AY E TS FOR PA <br />MEDICAL PAYMENTS FOR PARTICIPANTS <br />PRIMARY MEDICAL <br />DES <br />Certified <br />RIPTI NOF PERATI N / ATI N / E (Arno- A <br />Instructor of Aerobics, Aquatic exercise, Exercise, <br />RD , drlitional Remarks c adv 6,I <br />Strength, ZUMBAO <br />Morespace srequrtedj <br />EXCESS MEDICAL <br />The <br />certificate holder i5 added as an additional Insured. but <br />i with rocr.nrl m me ll,kn:r....I.:__ <br />4omi wwlC muLueH - CANCELLATION - .�.._.. -�. ...° -- " " °,•, =u a„wa. <br />City of Santa Ana, Its officers, agents and employees SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />Attn: Carmen Acosta 1$25 W. Civic Center, City of Santa Ana Parks & THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE <br />Recreatio WITH THE POLICY PROVISIONS. <br />Santa Ana, CA 92701 AUTHORIZED REPRESENTATIVE <br />(Owner /Lessor of Premises) 166 j .,. / / <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 (2010105) The ACORD name and 1090 are registered marks of ACORD 01988.2010 ACORD CORPORATION. All rights reserved. <br />APPROVED AS TO FORM <br />LISA E, STORCK <br />Assistant City Attorney , <br />