SIMON, LAURA 2 - 2012 - Laserfiche WebLink

Home Browse Search

DATE (MM /DD/YYYY) ACOROTM CERTIFICATE OF LIABILITY INSURANCE o3 /2a /zoiz 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 INSURERS), AUTHORIZED REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must 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 endorsements . PRODUCER K8K Insurance Group, Inc. '17'12 Magnavox Way Fort Wayne Indiana 46804 CONTACT NAME: MISS MerCh Dnderwrltln PHONE: (ac, No. E :t): 888 - 580 -804'1 FAx: (ac, No): 260- 459 -5995 E -MAIL ADDRESS: Info fi[nessinsurance- kk.com PRODUCER CUSTOMER ID #: INSURED Laura Lorraine Simon 1227 E. '14TH STREET SANTA ANA, CA 9270'1 A Member of the Sports, Leisure 8 Entertainment RPG INSURERS AFFORDING COVERAGE NAIC # INSURER A: NatlOnWlde Mutual Insurance Com an 23787 INSURER B: GENERAL LIABILITY INSURER C: INSURER D: 03/28/20'12 COVERAGES CERTIFICATE NUMBER: WOO'169660 REVISION NUMBER: 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. INS LTR TYPE OF INSURANCE ADDL INSR SUER WVD POLICY NUMBER POLICY EFF MM /DD/YY POLICY EXP MM /DD/YY LIMITS A GENERAL LIABILITY 66RPG0000005t42000 03/28/20'12 03/28/2013 EACH OCCURRENCE $'1,000,000 X COMMERCIAL GENERAL LIABILITY 7:49 PM EDT '12:0'1 AM DAMAGE TO RENTED PREMISES Ea occurrence $500,00 CLAIMS -MADE � OCCUR MED EXP (Any one person) $� O 000 PERSONAL & ADV INJURY $1 ,000,000 GENERAL AGGREGATE $3 000 000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PROJECT �LOC PRODUCTS - COMP /OP AGG $� 000,000 PROFESSIONAL LIABILITY $'1,000,000 LEGAL LIAR TO PARTICIPANTS $1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea Accitlent BODILY INJURY (Per parson) ANY AUTO BODILY INJURY (Per accident) ALL DWNED AUTOS SCHEDULED AUTOS PROPERTY DAMAGE Per accident HIRED AUTOS NON -OWNED AUTOS Not provitletl while in Hawaii . O FO M UMBRELLA LIAB OCCUR EACH OCCURRENCE AGGREGATE EXCESS LIAB CLAIMS -MADE DEDUCTIBLE �' ._Q RETENTION — Stitt S CCay WORKERS COMPENSATION AND EMPLOYERS' LIABLITY Y / N N / A Ati51S Cant Clt AttO rI1C WC STATU- TORY LIMITS OTHER ANY PROPRIETORSHIP /PARTNER/ EXECUTIVE OFFICE R/M EMBER E.L. EACH ACCIDENT E.L. DISEASE — EA EMPLOYEE EXCLUDED? (Mandatory in NH) If yes, describe under E.L. DISEASE — POLICY LIMIT DESCRIPTION OF OPERATIONS below MEDICAL PAYMENTS FOR PARTICIPANTS PRIMARY MEDICAL EXCESS MEDICAL DE RIPTI N F P RATI N / L ATI N / VEHI LE (Attach A RD 101, Additional Remarks chedule, if more apace is required Certified Instructor of: Aerobics, Aquatic exercise, Exercise, ZUMBA® The certificate holder is added as an additional insured but onl with res ect to the liabili arisin out of the o erations of the insured named above. CERTIFICATE HOLDER CANCELLATION City of Santa Ana, its officers, agents and employees SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Attn: Carmen Acosta '1825 W. Civic Center, City of Santa Ana Parks 8. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ReCreatio ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATVE Santa Ana, CA 9270'1 (Owner /Lessor of Premises) ��(- :� Coverage is only extended to U.S. events and activities. " 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 ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD ©'1988 -2009 ACORD CORPORATION. All rights reserved.