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DATE (MMIODNYYY) <br />n?/1 R/7M 9 <br />THIS 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 />THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED <br />REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER. <br />IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the <br />terms and conditions of the policy,certain p0ltcies 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 />NAME: Mass March Underwriting <br />K&K Insurance Group, Inc. <br />1712 Magnavox Way <br />Fort Wayne Indiana 46804 <br />1 0 /"s C7 O/1 <br />/"J <br />� <br />PRONE: 888-580-8041 FAX: (A/C, Do). 60-459.5995 <br />AID No EO: <br />EODaess:infoQfitnessinsurance-kk.com <br />INSURER(S) AFFORDINO COVERAGE NAICk <br />/I/- l/ / v <br />INSURERA: INailonwide Mutual Insurance Company 23787 <br />INSURED <br />INSURER a: <br />Marla L Madrigal <br />NSORER C: <br />2530 W Hood Ave <br />Santa Ana, CA 92704 <br />A Member of the Sports, Leisure & Entertainment RPG <br />MsuaeR a: <br />IN6ufleR E: <br />INSURER R <br />THIS 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 />SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br />INS <br />LTR <br />TYPE OF INBURANOR <br />ADOL <br />INSR <br />3 BR <br />WVD <br />POLICY NUMEBR <br />POLICY EFF <br />MMIO <br />POLICY EXP <br />MMDb <br />LIMITS <br />A <br />I GENERA"'AalLm <br />X <br />6BRPGOOD0005342300 <br />p2/13/2013 <br />02!13/2014 <br />%N1"AM <br />EACHOCCURRENOE $1,OD0,000 <br />X COMMERCIALOENERALLIABILITY <br />CLAIMS-MADE[XOCCUR <br />717 PM EDT <br />IDAMA011ORENTC0 $500,00 <br />PREMISES Eaoccurrence <br />MEDEXP(Any one persml 10,000 <br />PER EONALBADV INJURY $1,000,000 <br />rGRBGATE <br />GENERAL AGGREGATE 5,000,000 <br />LIMIT APPLIES PER: <br />CY ❑PROJECT F-�I-OC <br />PRODUCTS-COMP)OPAGG $1000000 <br />PROFESSIONAL LIABILITY $1,000,000 <br />LEGAL LIAR TO PARTICIPANTS $1,000,000 <br />AUTOMOBILE <br />LIABILITY <br />COMBINED SINGLE LIMIT <br />EaAwldenl <br />ANY AUTO <br />ALL OWNED AUTOS CHEOOLED <br />UTOS <br />BODILY INJURY (Per person) <br />90DILV INJURY (P.,.cd <br />HIRED AUTOS NON -OWNED <br />UTO- <br />PROPERTY DAMAGE <br />Peracddenl <br />Notpowlded while In Newell <br />UMBRELLA LIPS OCCUR <br />JEACLIOCCURRENCE <br />EXCESS LIAB CLAIMS -MADE <br />AGGREGATE <br />DEO RETENTION <br />WORKERS COMPENSATION <br />AND EMPLpYERS'UABILITV YIN <br />ANY PROFRIETORSHIP/PARTNEW <br />EXECUTIVE OFFICEMMEMBER <br />EXCLUDED? <br />(Mandatory In NH) <br />N/A <br />WC STATU- <br />TORY LIMITS OTHER <br />E.L. EACH ACCIDENT <br />E.L. DISEASE -EA EMPLOYEE <br />EL OISEASe-POLICY LIMIT <br />If yes, descdbe u,Wer <br />DESCRIPTION OF OPERATIONS below <br />MEDICAL PAYMENTS FOR PARTICIPANTS <br />PRIMARY MEDICAL <br />EXCESS MEDICAL <br />DE6GflIPT ON OF OP ERA I ION /LOCATIONS E CLE6 Attach ACORD 101,A tliFiona emar s o e ee, Irmere space srequ retl <br />Certified Instructor of: ZUMBA® <br />The pertifiCata holder Is added as an -additional Insured, but only with respect to theNCELLATIONiabilli adsin out of the operations of the insured named above. <br />7A <br />City of Santa Ana, Its officers, agents, and employees <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />1826 W CIVIC Center <br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE <br />Santa Ana, CA 92704 <br />WITH THE POLICY PROVISIONS. <br />AUTHORIZED�REPRESSEENTATTIIVE <br />(Owner/Lessor 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 (2010105) The ACORD name and logo are registered marks of ACORD U 19002010 ACORD CORPORATION. All rights reserved. <br />APPROVED .AS 710 <br />LISRCK' <br />Assistant City / i,wnev �� <br />