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2013 7 u <br />ACORDW CERTIFICATE OF LIABILITY INSURANCE <br />DATE `MMI°° Y Y, <br />10/31/201 a <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 />HIS 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 />arms 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 />K&K Insurance Group, Inc. <br />1712 Magnavox Way <br />Fort Wayne IN 46804 <br />CONTACT NAME: Mass Merchandising <br />PHONE (wc, No. Ext): 1.800.506.4856 FAx (Alc, No): 1-260459-5590 <br />E-MAIL ADDRESS: Info@fitnesslnsurance-kk.com <br />INSURED 2000336959 CP#6419 <br />Nancy Lopez <br />911 S Golden West Avenue <br />Santa Ana, CA 92704 <br />Member of the Sports, Leisure & Entertainment RPG <br />INSURER(S) AFFORDING COVERAGE NAICB <br />INSURER A: Nationwide Mutual Insurance Company 23787 <br />INSURER B: <br />INSURER C: <br />INSURER D:-� <br />MIS 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 />R <br />LTR <br />TYPE OF INSURANCE <br />ADDL <br />jNSR <br />SUER <br />MD <br />POLICY NUMBER <br />POLICY EFF <br />(MMIDDIYY) <br />POLICY EXP <br />(MM/DOIYY) <br />LIMITS <br />A <br />GENERAL LIABILITY <br />X <br />6BRPG0000005342300 <br />10/25113 <br />10/25/14 <br />EACH OCCURRENCE $1,000,000 <br />X COMMERCIAL GENERAL LIABILITY <br />4:23 PM EDT <br />12:01 AM <br />DAMAGE TO RENTED <br />PREMISES Ea occurrence $500,000 <br />CLAIM$-MAOEa OCCUR <br />MED EXP (Any one person) $10,000 <br />PERSONAL& ADV INJURY $1.000,000 <br />GENERAL AGGREGATE $5,000,000 <br />GENT. AGGREGATE LIMIT APPLIES PER: <br />PRODUCTS-COMPIOP AGO $1,000,000 <br />POLICY F—] PROJECT OLOC <br />PROFESSIONAL LIABILITY $1,000,000 <br />LEGAL LIAS TO PARTICIPANTS $1,000,000 <br />AUTOMOBILE LIABILITY <br />COMBINED SINGLE LIMIT <br />Ea Accident <br />BODILY INJURY (Par person} <br />ANY AUTO <br />ALL OWNED AUTOS SCHEDULED <br />HIRED AUTO$ NON -OWNED <br />HX <br />�Ty�+�gpr <br />yt YT'{,LJ V Y+tJ <br />F'L x <br />Y 0 <br />v7 <br />"Lk <br />BODILY INJURY (Per accident) <br />PROPERTY DAMAGE <br />Par accident <br />Not provided w1rileln Hawaii <br />UMBRELLA LIAR OCCUR <br />EXCESS LIAB CLAIMS- MAGE <br />OED F—IRETENTiON <br />✓ <br />P,5S15tO <br />5T <br />¢ GiLy j{�iG <br />�I <br />iIDF <br />EACH OCCURRENCE <br />AGGREGATE u <br />WORKERS COMPENSATION <br />WCSTATU- <br />OTH- <br />AND EMPLOYERS' LIABILITY YIN <br />ANY PROPRIETORIPARTNEW ❑ <br />EXECUTIVE OPFICERIMEMSER <br />EXCLUDED? <br />N/A <br />TORY LIMITS <br />ER <br />E.L. EACH ACCIDENT <br />E.L. DISEASE -EA EMPLOYEE <br />(Mandatory to NH) <br />E.L, DISEASE- POLICY UMn <br />If yes, describe under <br />DESCRIPTION OF OPERATION$ below <br />MEDICAL PAYMENTS FOR <br />PRIMARY MEDICAL <br />PARTICIPANTS <br />EXCESS MEDICAL <br />DESCRIPTION OF OPERATIONS! LOCATIONS I VEHICLES (Anadh ACORD 1 11, Additional Remarks Schedule, It more space is required) <br />Certified Instructor of: ZUMBA® <br />The Certificate holder is added as an additional insured, but only with respect to liability arising out of the operations of the insured named above, <br />'**Void and replace certificate #W00387338*** <br />ucn urwP,1 c nuwcr< <br />City of Santa Ana <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED <br />Parks, Recreation and Community Services Agency <br />BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />Attn: Carmen Acosta <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />1825 W CIVIC (renter <br />AUTHORIZED REPRESENTATIVE <br />Santa Ana, CA 92701 <br />/J,• ,,y,_ <br />Owner/Manager/Lessor of Premises <br />%� "r'N^^�' <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 reserved. <br />The ACORD name and logo are registered marks of ACORD <br />