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ACORDTN CERTIFICATE OF LIABILITY INSURANCE 1 tlAT312712D/YYYY) <br />08 / 3 <br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON <br />THE CERTIFICATE HOLDER. THIS <br />HOLD <br />DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND ORALTER THE COVERAGE AFFORDED <br />ICERTIFICATE <br />BY THE POLICIES BELOW. <br />THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURERS), AUTHORIZED <br />REPRIESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. <br />IMPORTANT: If the certificate holder Is ii ADDITIONAL INSURED, the policy(les) 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 endorsement a . <br />PRODUCER <br />CONTACT <br />NAME: <br />Mass March Underwriting <br />K &K Insurance Group, Inc. <br />1712 Magnavox Way <br />Arc Nd. Ext : <br />888.580.8041 <br />FAx: (q/C, No): <br />28p•459 -5995 <br />Fort Wayne Indiana 48804 <br />ADDRRESS: <br />info @ftnessinsurance•kk.com <br />rGEN'LAGGRE <br />INSURER(Iii) AFFORDING COVERAGE <br />NAICR <br />INSURED <br />NSURERAr <br />Nationwide Mutual Insurance( -no a0 <br />237$7 <br />GATE LIMIT APPLIES PER; <br />CY ❑PROJECT �LOC <br />INSURER B: <br />$1000 ,00 <br />PROFESSIONAL UgBILITY <br />Laura Lorraine Simon <br />1227 E. 14TH STREET <br />INSURER C: <br />INSURER Or <br />AUTOMOBILE LIABILITY <br />SANTA ANA, CA 92701 <br />INSURER E: <br />A Member of the Sports, Leisure & Entertainment RPG <br />INSURER F: <br />ANYAUTO <br />COVERAGES rcDT.. <br />rv��cororu nC <br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE L vlslON NUMBER: <br />NOTWITHSTANDING <br />ISSUED <br />SUCH <br />NS <br />LTR <br />A <br />ANY REQUIREMENT, TERM <br />OR MAY PERTAIN, THE INSURANCE <br />POLICIES. LIMITS SHOWN MAY HAVE BEEN <br />TYPB OF <br />GENERAL LIABILITY <br />MERCIAL GENERAL LIABILITY <br />CLAIMS -MADE 7000UR <br />OR <br />AFFORDED <br />REDUCED <br />ADDL <br />INSR <br />CONOT <br />BY <br />SUER <br />MD <br />pN ISTEDBELOWHAVE <br />CONTRACT OR <br />THE POLICIES DESCRIBED HEREIN <br />BY PAID CLAIMS. <br />POLICY NUMBER <br />68RPGOD00005342300 <br />OTHER DOCUMENT <br />IS SUBJECT <br />POLICY EFF <br />MMIDD <br />03/27/2013 <br />5:30 PM EDT <br />W THMRESPECT <br />TO ALL THE <br />POLICY &I <br />MMIDDIYY <br />03/27/2014 <br />12:01 AM <br />TO WH CH THIS CERTIF LATE MAY BE <br />TERMS, EXCLUSIONS AND CONDITIONS OF <br />LIMITS <br />EACH CCCURRENCE $1,000,00 <br />DAMAGE TO RENTED <br />PREMISES Ea oxurtence <br />MED EXP(Any one person) <br />$$00,000 <br />$16' "' <br />PERSONAL &ADV INJURY <br />$1,000,00 <br />GENERAL AGGREGATE <br />$5,000,0' <br />rGEN'LAGGRE <br />GATE LIMIT APPLIES PER; <br />CY ❑PROJECT �LOC <br />PROOUCTS•GOMP /qP AGG <br />$1000 ,00 <br />PROFESSIONAL UgBILITY <br />$1,000,00 <br />AUTOMOBILE LIABILITY <br />LEGAL LIAS TO PARTICIPANTS <br />COMBINED SINGLE LIMIT <br />$1,505,'6'0 <br />ANYAUTO <br />Ea Arxident <br />BODILY INJURY (Per person) <br />ALL OWNED AUTOS SCHEDULED <br />UTOS <br />HIRED AUTOS urros NED <br />UTOS <br />Not proNtletl wlAle In Hawall <br />ROPILY INJURY (Per accident) <br />PROPERTYDAMAGE <br />Per accident <br />UMBRELLALIAB OCCUR <br />EXCESS LIAB CLAIMS -MAOE <br />EACH OCCURRENCE <br />AGGREGATE <br />COMPENSATION <br />OYERS'LIABIUTY YrN <br />RIETORSHIRPARTNERt <br />WCSTATU. <br />TORY LIMITS <br />OTHER <br />rANYRETENTION <br />p FFICER/MEMBER � <br />in N H) <br />be under <br />N/A <br />E.L. EA CH ACCIDENT <br />E.L. DISEASE —EA EMPLOYEE <br />ION OF OPERATIONS helve <br />E,L. DISEASE — POLICY LIMIT <br />MEDICAL PAYMENTS FOR PARTICIPANTS <br />PRIMARY MEDICAL <br />EXCESS MEDICAL <br />DESCRIPTION F oro N (AtMc A RD ,A dtlona mar s c e ue, more spore sregteratl <br />Certified Inslructorof: Aerobics, Aquatic exercise, Exercise, Strength, ZUMBI <br />Abuse, Molestation, Harassment or Sexual Conduct Defense Cost Rolmburi ement- $100,000 limit <br />CERTIFICATE HOLDER CANCELLATION <br />Evidence of CoveragO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE <br />WITH THE POLICY PROVISIONS. <br />AUTHORIZED REPRESENTATIVE <br />Coverage is only extended to U.S. events and activities. <br />*' NOTICE TO TEXAS INSUREDS: The Insurer forthe 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 logo are registered marks of ACORD @ 1988 -2010 ACORD CORPORATION. All rights reserved. <br />APPROVED AS TO FORM <br />LISA E, STORCK <br />_. Assistant City Attorney <br />