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ACORD.. CERTIFICATE OF LIABILITY INSURANCE <br />F DATE(MM/DDIYYYY) <br />01 /2612015 <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 INSURERS), AUTHORIZED <br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. <br />IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) 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 endorsements . <br />PRODUCER <br />CONTACT NAME: Mass Merchandising <br />K&K Insurance Group, Inc. <br />Fort Magnavox Way <br />Fort Wayne IN 46804 <br />PHONE(AIC, No. Ext): 1-800-328-2317 IFAX(A/C, No): 1-260-459-5502 <br />E-MAILADDRESS: info@eventinsurance-kk.com <br />@ <br />INSURED 2000351738 CP#470 <br />INSURER(S) AFFORDING COVERAGE <br />NAIC# <br />Felice Ilkcagla <br />3436 Taurus Lane <br />Santa Ana, CA 92704 <br />Member of the Sports, Leisure & Entertainment RPG <br />INSURER A: Nationwide Mutual Insurance Company <br />23787 <br />INSURER B: <br />INSURER C: <br />INSURER D: <br />COVERAGES Utt( I III I t NUMt3hK: 200018111 3 REVISION NUMBER: <br />HIS 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 />TYPE OF INSURANCE <br />ADDL <br />INSD <br />SUBR <br />WVD <br />POLICY NUMBER <br />POLICY EFF <br />(MMIDD/YY <br />POLICY EXP <br />(MMIDD/YV <br />LIMITS <br />A <br />X <br />COMMERCIAL GENERALUABILITY <br />X <br />6BRPG000OCO5576800 <br />01/14/15 <br />01/14/16 <br />EACH OCCURRENCE <br />CLAIMS-MADE OCCUR <br />12:01 AM <br />12:01 AM <br />DAMAGE TO RENTED <br />PREMISES (Ed occurrence <br />MILD EXP (Any one person) <br />;$5,000 <br />PERSONAL&ADV INJURY <br />GEN'L AGGREGATE LIMIT APPLIES PER'. <br />PROJECT �LOC <br />GENERAL AGGREGATEPOLICY <br />OTHER <br />PRODUCTS-COMP/OP AGG <br />$1,000,000 <br />PROFESSIONAL LIABILITY <br />$1,000,000 <br />LEGAL LIAB TO PARTICIPANTS <br />$1,000,000 <br />AUTOMOBILE LIABILITY <br />Reviewed <br />by. <br />COMBINED SINGLE LIMIT <br />Accident <br />ANY AUTO <br />ALL OWNED AUTOS <br />R GYV G-+ <br />IJ'r <br />O <br />BODILY INJURY (Per person) <br />BODILY INJURY (Per accident) <br />eAUTOSULED <br />HIREDAUTOS NON -OWNED <br />AUTOS <br />PROPERTY DAMAGE <br />Per accident <br />/r <br />X Nat provided while in Hawaii <br />Sllin�^, <br />UMBRELLA LIAB OCCUR <br />rt+r <br />ICSAI <br />EACH OCCURRENCE <br />EXCESS LIAB CLAIMS -MADE <br />"Kry <br />,L� 't��y�(Y,' <br />" <br />AGGREGATE <br />RETENTION <br />DED 71 <br />WORKERS COMPENSATION <br />AND EMPLOYERS' LIABILITY YIN <br />ANY PROPRIETOR/PARTNER/ <br />IPER <br />ISTATUTL <br />OTHER <br />E.L. EACH ACCIDENT <br />EXECUTIVE OFFICER/MEMBER <br />EXCLUDED? <br />(ory in NH) <br />NIA <br />E.L. DISEASE - EA EMPLOYEE <br />es, describe under <br />Iff yes, d <br />DESCRIPTION OF OPERATIONS <br />E.L. DISEASE - POLICY LIMIT <br />be. <br />MEDICAL PAYMENTS FOR PARTICIPANTS <br />PRIMARY MEDICAL <br />EXCESS MEDICAL <br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if mom space is inquired) <br />Instructor of: Craft making & Instrumental music <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 />** This certificate voids and replaces certificate #2000178736 "* <br />CERTIFICATE HOLDER CANCELLATION <br />City Of Santa Ana It's Officers, Agents, Employees, and Volunteers SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />20 Civic Center Plaza THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />Santa Ana, CA 92701 ACCORDANCE WITH THE POLICY PROVISIONS. <br />Owner/Manager/Lessor of Premises AUTHORIZED REPRESENTATIVE <br />law -;t <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 (2014/01) @ 1988-2014 ACORD CORPORATION. All rights reserved. <br />The ACORD name and logo are registered marks of ACORD <br />