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ACOROrM CERTIFICATE OF LIABILITY INSURANCE <br />DATE (MM/DD/YYYY) <br />03/14/2012 <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 />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(s). <br />PRODUCER <br />CONTACT NAME: Mass Merchandising <br />K&K Insurance Group, Inc. <br />PHONE (A/C, No. Ext): 1-800-506-4856 1FAX (A/c, No): 1-260-459-5590 <br />1712 Magnavox Way <br />Fort Wa ne IN 46804 <br />E-MAIL ADDRESS: infoCfitnessinsurance-kk.com <br />INSURED 10193885 CP# 1291 <br />INSURER(S) AFFORDING COVERAGE NAIC N <br />Maria L Madrigal <br />INSURER A: Nationwide Mutual Insurance Company 23787 <br />530 W Hood Ave <br />INSURER B: <br />Santa Ana, CA 92704 <br />Member of the Sports, Leisure & Entertainment RPG <br />INSURER C: <br />INSURER D: <br />COVERAGES CERTIFICATE NUMBER: 2000046199 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 O <br />SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br />INS I <br />R <br />TYPE OF INSURANCE <br />ADDL <br />SUBR <br />POLICY NUMBER <br />POLICY EFF <br />POLICY EXP <br />LIMITS <br />LTR <br />INSR <br />WVD <br />(MM/DD/YY) <br />(MM(DD/YY) <br />A <br />GENERAL LIABILITY <br />6BRPG00000051 42000 <br />02/06/12 <br />02/06/13 <br />EACH OCCURRENCE $1,000,000 <br />2:11 AM EDT <br />12:01 AM <br />DAMAGE TO RENTED <br />X COMMERCIAL GENERAL LIABILITY <br />PREMISES Ea occurrence $500,000 <br />CLAIMS-MADEFX__JOCCUR <br />MED EXP (Any one person) $10,000 <br />PERSONAL 8 ADV INJURY $1,000,001) <br />GENERAL AGGREGATE <br />$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 $1,000,00c) <br />AUTOMOBILE LIABILITY <br />COMBINED SINGLE LIMIT <br />Ea Accident <br />BODILY INJURY (Per person)ALL <br />NYAUTO <br />SCHEDULED <br />OWNED AUTOS <br />BODILY INJURY (Per accitlent) <br />AUTOS <br />PROPERTY DAMAGEAUTOS <br />HIRED AUTOS NON -OWNED <br />Per accidentJA <br />Not provided while in Hawaii <br />MBRELLA LIAR OCCUR <br />_ ° - 'S <br />�QR <br />EACH OCCURRENCE <br />EXCESS LIAR CLAIMS- <br />AGGREGATE <br />MADE <br />RETENTION <br />_ <br />WORKERS COMPENSATION.t <br />AND EMPLOYERS' LIABILITY Y / N <br />.i - t <br />`� y <br />WC STATU- OTH- <br />TORY LIMITS ER <br />ANY PROPRIETOR/PARTNER/ <br />tty (k <br />Orne y <br />E.L. EACH ACCIDENT <br />EXECUTIVE OFFICER/MEMBER <br />N / A <br />E.L. DISEASE — EA EMPLOYEE <br />EXCLUDED? <br />(Mandatory in NH) <br />E.L. DISEASE — POLICY LIMIT <br />If yes, tlescribe 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 Remarks Sohedula, if more apace la requli ed) <br />Certified Instructor of: ZUMBAOO <br />bove. <br />The certificate holder is added s an dditional insured, but only with respect to the liability arising out of the operations of the insured named above- <br />a <br />---aces Certificate #WO0154712 Effective 03/08/12 -02/06/13*' - <br />"'This Certificate voids and re la <br />CERTIFICATE HOLDER CANCELLA I IVN <br />City of Santa Ana, its officers, employees, agents and representatives <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED <br />20 Civic Center Plaza <br />BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />Santa Ana, CA 92701 <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />Owner/Manager/Lessor of Premises <br />AUTHORIZED <br />/REPRESENTATIVE <br />A� <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 (2010/05) © 1988-2010 ACORD CORPORATION_ All rights reserver!. <br />The ACORD name and logo are registered marks of ACORD <br />