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ACORDTM CERTIFICATE OF LIABILITY INSURANCE <br />DATE(MMiDD1YYYY) <br />02/13/2014 <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 C ,I IOAkT HO D@ t. of <br />IMPORTANT: If the certificate holder is an ADDI -I ' A LSINSU ED, I a policy(ies) must he 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 />PRODUCERTACT <br />- �% E •„3 _i: <br />A I iMass Merch Underwriting <br />K&K Insurance Group, Inc. -' <br />1712 Magnavox Way <br />Fort Wayne Indiana 46804 <br />Y <br />PHo E: 888-580-8041 FAX: (AIC, No): 260-459-5995 <br />Arc No. Ext <br />E-MAIL info fitnessinsurance-kk.com <br />ADDRESS: <br />INSURERIS) AFFORDING COVERAGE NAIC if <br />INSURER A: Nationwide Mutual Insurance Company 23787 <br />INSURED <br />INSURER B: <br />Maria L Madrigal JL a —o <br />2530 W Hood Ave sif ` C 1 <br />Santa Ana, CA 92704 <br />A member of the Sports, Leisure & Entertainment RPG <br />INSURER C: <br />INSURER D: <br />INSURER E: <br />INSURER F: <br />GUVERAII CERTIFICATE NUMBER: W00421873 REVISION NUMBER: <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 ALI THE TERMS, EXCLUSIONS AND CONDITIONS OF <br />SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br />INSR <br />LTR <br />TYPE OF INSURANCE <br />ADDL <br />INSR <br />SUBR <br />WVD <br />POLICY NUMBER <br />POLICY EFF <br />MMIDDY <br />IY <br />POLICY EXP <br />MMIDDIY`( <br />LIMITS <br />A <br />X COMMERCIAL GENERAL LIABILITY <br />X <br />6BRPG0000005515500 <br />02/13/2014 <br />02/1312015 <br />EACH OCCURRENCE $1,000,00 <br />CLAIMS -MADE X OCCUR <br />1:45 PM EDT <br />12:01 AM <br />DAMAGE TD RENTED $500,000 <br />PREMISES Ea occurrence <br />MED EXP (Any one person) $10.000 <br />PERSONAL &ADV INJURY $1,000,000 <br />GEN'IAGGREGATE LIMIT APPLIES PER: <br />POLICY1-1 PRO- LOC <br />J CT <br />GENERAL AGGREGATE $5,000,00 <br />PRODUCTS-COMP/OP AGG <br />$1,000,00 <br />PROFESSIONAL LIABILITY $1,000,00 <br />OTHER <br />.� <br />-.'1 <br />LEGAL LIAB TO PARTICIPANTS $1,000,00 <br />AUTOMOBILE LIABILITY�T2 <br />.'-a <br />!L� <br />COMBINED SINGLE LIMIT <br />Ea Accident <br />ANY AUTO <br />ALL OWNED AUTOS SCHEDULED <br />AUTOS <br />ONO- OWNED <br />HIRED AUTOS ' , _ .- AUTOS <br />Not provided while in HawaiiS°o1^'�� <br />,�"'�d <br />v „�-.1,-�v` <br />�,- - -� -�:; 'q'I� <br />�'� <br />- <br />5 \� <br />RCtOit�e <br />BODILY INJURY (Per person) <br />BODILY INJURY (Per ancident) <br />peOa cidentDAMAGE <br />EACH OCCURRENCE <br />IUMBRELLALIAII <br />[,::]OCCUR <br />EXCESS I CLAIMS -MADE <br />AGGREGATE <br />DED F71RETEN <br />WORKERS COMPENSATION <br />AND EMPLOYERS' LIABILITY Y/N <br />ANY PROPRIETORSHIPIPARTNERI <br />EXECUTIVE OFFICERIMEM6ER <br />EXCLUDED? <br />N r A <br />PER OTHER <br />STATUTE <br />F1. EACH ACCIDENT <br />E.L. DISEASE EA EMPLOYEE <br />(Mandatory in NH) <br />If yes, describe under <br />DESCRIPTION OF OPERATIONS below <br />E.L. DISEASE- POLICY LIMIT <br />MEDICAL PAYMENTS FOR PARTICIPANTS <br />PRIMARY MEDICAL <br />EXCESS MEDICAL <br />DIM( RIPTION FL ATIONS VEHICLES A ll , Additional Remarks Schedule, may be attached it more space is required <br />Certified Instructor of: Aerobics, Dance, ZUMBA(�) <br />The certificate holder is added as an additional insured, but onlywith respect to the liabilityarisin out of the o erations of the insured named above. <br />CERTIFICATE HOLDER CANCELLATION <br />City of Santa Ana, its officers, agents, and employees <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />1825 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 REPRESENTATIVE <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 (2014101) The ACORD name and logo are registered marks of ACORD O 1988-2014 ACORD CORPORATION. All rights reserved. <br />