Laserfiche WebLink
Jda <br />'Al 1 <br />ACORD,. CERTIFICATE OF LIABILITY INSURANCE <br />DATDIYYYY) <br />055!28/212612014 <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 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 Mass MerchandisingUnderwriting <br />NAME: g <br />K&K Insurance Group, Inc.PHONE: <br />1712 Magnavox Way <br />Fort Wayne IN 46804 <br />1-800-$06-4566 PAX:(AIC,No): 1- <br />AIC No. Et: 260-469-$$90 <br />Z-MAILIDDRESS! Info@Fltnessinsurance-klccom <br />INSURER(S) AFFORDING COVERAGE NAIGN <br />X <br />INSURER A: Nationwide Mutual Insurance Company 23787 <br />INSURED <br />INSURER a'. <br />Laverne Davis <br />INSURER C. <br />2221 S. Lowell at. <br />INSURER D: <br />Santa Ana, CA 92707 <br />A Member of the Sports, Leisure & Entertainment RPG <br />INSURER E: <br />INSURER F: <br />COVERAGES CERTIFICATE NUMBER: W00466618 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 ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF <br />SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br />INSR <br />LTR <br />TYPEOFINSURANCE <br />ADDL <br />INSD <br />SUER <br />MO <br />POLICY NUMBER <br />POLICY EFF <br />MMNDNY(MMA)DI") <br />POLICY EXP <br />LIMITS <br />A <br />X <br />COMMERCIAL GENERAL LIABILITY <br />X <br />6BRPG0000005527000 <br />06/08/2014 <br />06108/2015 <br />EACH OCCURRENCE $1,000,00 <br />CLAIMS -MADE OCCUR <br />LLL JJJ <br />12:01 AM EDT <br />12:01 AM <br />DAMAGE TO RENTED $300,000 <br />PREMISES Ea occurrencJ_ <br />MED EXP (My one person) $5,000 <br />PERSONAL &ADV INJURY $1,000100 <br />GEN': AGGREGATE LIMIT APPLIES PER'. <br />GENERALAGGREGATE <br />PRO, ❑ LOC <br />POLICY ❑ <br />JECT <br />OTHER <br />py�� <br />-Voll r1 <br />$5.000 00 <br />PRODUCTS-COMP/OP AEG <br />$t 00000 <br />____ <br />PROFESSIONAL LIABILITY $1,000,00 <br />t 1L+ <br />VF+^ <br />To <br />34` <br />LEGAL LIAS TO PARTICIPANTS $1,000,00 <br />AUTOMOBILE LIABILITY <br />ANYAUTO <br />SCHEDULED <br />OWNEb AUTOS I�—jILe;UTOS <br />HIREDAUTOS "ON -OWNED <br />iLL......JJJHeeUT05 <br />r �" <br />LIS <br />Assists <br />keKALL <br />r.�-- <br />rney .,.. <br />`✓/�,"T, <br />OMBINED SINGLE LIMIT <br />Ea Acaldenf <br />BODILY INJURY (Per person) <br />BODILY INJURY (Per accident) <br />PROPERTY OAHIAGE <br />Peraccident <br />Not provided while in Hawaii <br />UMBRELLALIAB OCCUR <br />EACH OCCURRENCE <br />EXCESS LIAR CLAIMS -MAGE <br />AGGREGATE .._ <br />DED LLL RETENTION <br />WOR HERS COMPENSATION <br />AND EMPLOYERS'LIAaILITY YIN <br />'-" '_-- <br />__--- <br />___-- <br />PER <br />"-"'STATUTE <br />ANY PROPRIETORSHIP/PARTNERI <br />EXECUTIVE OFFICER/MEMBER <br />EXCLUDED? <br />N / A <br />E.L. EACH ACCIDENT <br />E.L. DISEASE -EA EMPLOYEE <br />(Mandatory In NH) <br />—` <br />If yes, describe under <br />E.L. DISEASE - POUCY LIMIT <br />DESCRIPTION OF OPERATIONS below <br />MEDICAL PAYMENTS FOR PARTICIPANTSPRIMARY <br />MEDICAL <br />EXCESS MEDICAL <br />DR RI TI N OF OPERATIONS I L XTIMNS I EHIULEs(A RD 101, Additional Remarks Schedule, may be attached it more space is required) <br />Certifled Instructor of: ZUMBA (R) <br />The certificate holder is added as an additional Insured, but only for liability caused, In whole or In part, by the acts or omissions of the named insured. <br />CERTIFICATE HOLDER CANCELLATION <br />The City of Santa Ana and its ofricars,empioyeos,agents&representatives <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />Attn:Carmen Acosta, 1826 W. Civic Center <br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE <br />Santa Ana, CA 92701 <br />(Owner/Lessor Of Premises) <br />WITH THE POLICY PROVISIONS. <br />AUTHORIZED REPRESENTATIVE <br />/Wv /'. <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 01988.2014 ACORD CORPORATION. All rights reserved. <br />