DAVIS, LAVERNE - 2012 - Laserfiche WebLink

Home Browse Search

CERTIFICATE OF LIABILITY INSURANCE DAT7/20/2012 I) ROTM o7/zo/zo1 z HIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS ERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW HIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZE 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 th rms and conditions of the policy, certain policies may require an endorsement. A be on this certificate does not confer rights to the ertificate holder in lieu of such endorsements . PRODUCER CONTACT NAME: Mass Merchandising K&K Insurance Group, Inc. PHONE (A/C, No. Ext): 1-800-648-6406 FAX (A/C, No): 1-260-459-5940 1712 Magnavox Way Fort Wayne IN 46804 E-MAILADDRESS: infoQdanceinsurance-kk.com NSURED 2000064616 CP# 907 INSURER(S) AFFORDING COVERAGE NAIC Y La Veme Davis INSURER A: Nationwide Mutual Insurance Company 23787 221 S. Lowell Street INSURER B: ants Ana, CA 92707 INSURER C: Member of the Sports, Leisure & Entertainment RPG INSURER D: HIS 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 O SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INS BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Santa Ana, CA 92701 ACCORDANCE WITH THE POLICY PROVISIONS. Owner/Manager/Lessor of Premises AUTHORIZED REPRESENTATIVE R TYPE OF INSURANCE ADDL INSR SUER WVD POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR (MM/DD/YY) (MM/DDnr`n A GENERAL LIABILITY 6BRPG0000005155700 06/08/12 06/08/13 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY 12:01 AM EDT 12:01 AM DAMAGE TO RENTED CLAIMS -MADE F OCCUR PREMISES Ee occurtence $300,000 MED EXP (Any one parson) $5,000 PERSONAL 8 ADV INJURY $1,000,000 GENERALAGGREGATE $3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMP/OP AGG $1'000'000 POLICY =PROJECT O LOC PROFESSIONAL LIABILITY $1 000,000 LEGAL LIAB TO PARTICIPANTS $1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ee Accitlent ANY AUTO BOOILV INJURY (Per person) ALL OWNED AUTSCHEDULED OS AUTOS AYpgp V f.� t J 1 t_� L' y d'� Nt BODILY INJURY (Per eccitlenq HIREDAUTOS NON -OWNED PROPERTY DAMAGE AUTOS Par arcJtlen[ X Not provided while in Hawaii UMBRELLA LIAB Sjii:.Ldl' EACH OCCURRENCE HOCCIR EXCESS LIAB CLAIMS- MADE L,BllTd. St. /�tLUril. AGGREGATE ASS 1StHt1.i 1LY DED RETENTION WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS' LIABILITY Y1. TORY LIMITS ER ANY PROPRIETOR/PARTNER/ E.L. EACH ACCIDENT EXECUTIVE OFFICEWMEMBER N / A E.L. DISEASE — EA EMPLOY EE EXCLUDED? Mand story In Nnd If y- untler DES IPTIOe DESCRIPTION OF OPERATIONS below E_L. DISEASE —POLICY LIMIT MEDICAL PAYMENTS FOR PRIMARY MEDICAL PARTICIPANTS EXCESS MEDICAL DESCRIPTION OPERATIONS/ LOCATIONS /VEHICLES (Attach ACORD 101, Addltlonal Remerka Sehedule, If more space Is requlretl) Non-Certifiedd Instructor of: ZUMBA® The certificate holder is added as an additional insured, but only With respect to the liability arising out of the operations of the insured named above "'Void and replace certificate #WO0190998— 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 (2010/05) © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD liN1Y{.CLLA I IVIV The City of Santa Ana and it's officers, employees, agents and representatives SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 20 Civic Center Plaza BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Santa Ana, CA 92701 ACCORDANCE WITH THE POLICY PROVISIONS. Owner/Manager/Lessor of Premises AUTHORIZED REPRESENTATIVE 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 (2010/05) © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD