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C RDTN CERTIFICATE OF LIABILITY INSURANCE <br />OAT/01YYYY) <br />051265/26I2014 <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 corifleale holder is an ADDITIONAL INSURED, the poiloy(les) must be endorsed. if SUBROGATION IS WAIVED, subject tD 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 <br />NAME: <br />Mass Merchandisin Underwritin 9 <br />9 <br />K&K Insurance Group, Inc. -� _ <br />1712 Magnavox Way <br />Fort Wayne IN 46804 <br />PHONE: <br />AIC No. Ear: <br />_ <br />1-800-506-4866 _ <br />_ <br />FAXi(A/C, No): <br />1-260-459-5590 <br />gODRESS: <br />Info(o)fltne6SinSUrance-kk.cam <br />INSURER(S) AFFORDING COVERAGE <br />NAIC0 <br />INSURER A: <br />Nationwide Mutual Insurance Company <br />23787 <br />INSURED <br />8: <br />_ _INSURER <br />Laverne Davis _ <br />INSURER C:.�-�- <br />2221 s. Lowell St. <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 ALI. THE TERMS, EXCLUSIONS AND CONDITIONS OF <br />SUCH POLICIES. UNITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, <br />INSR <br />LTR <br />TYPE OFINSURANCE <br />ADDL <br />INSD <br />SUER <br />WVD <br />POLICY NUMBER <br />P LICYEFr^ <br />MMIDD <br />POLICYEXP <br />MMlDO/YY <br />LIMITS <br />A <br />X <br />COMMERCIAL GENERAL LIABILITY <br />X <br />68RPO0000005527000 <br />06/08/2014 <br />06/08/2016 <br />EACH OCCURRENCE <br />$1,000100 <br />DLAIMB•MADE X OCCUR <br />12:01 AM EDT12:01 <br />AM <br />DAMAGE RENrEO <br />PREMISES ocCiurance <br />$300,000 <br />-(Ea <br />MED EXP(Any one person) <br />$5,000 <br />PERSONAL &ADV INJURY <br />$1,000,00 <br />OEN'; AGGREGATE LIMIT APPLIES PER <br />GENERAL AGGREGATE <br />�"""_'i <br />POLICY' PRO- ❑ LOC <br />L_I JECT <br />OTHERpnpq <br />a� <br />'.Q ,yv1 <br />5 000 00 <br />PRODUCTS-COMPIDP AGG <br />$1 6D6,g0 <br />PROFESSIONAL LIABILITY <br />$1.000.00 <br />+f'@ <br />V �+ <br />O <br />LEGA _LAB TOPARTICIPANTS <br />$1,000,0O <br />AUTOMOBILE LIABILITY <br />OMe1NED SINGLE LIMIT <br />Ea Accldonl <br />_ <br />BODILY INJURY (Per person) <br />ANY AUTO <br />ALL OWNED AUTOS SCHEDULED urns <br />NON OWNED <br />HIRED AUTOS ON-O <br />L <br />o <br />LISP <br />As <br />F ity At <br />t C)ty Att <br />rney�. <br />�'' <br />5 <br />BODILY INJURY (Per anddenU <br />PROPERTY DAMAGEL_JAUTOG <br />Not provided while In Hawaii <br />✓ <br />UMBRELLALIAB OCcuR <br />EACHOCCURRENCE <br />EXCESS LIAS CIAIMS-MADE <br />AGGREGATE <br />�.. <br />DED RETENTION <br />... <br />WORKERS COMPENSATION <br />AND EMPLOYERS' LIABILITY YIN <br />ANY PROPRIETORSHIP/PARTNER/ <br />EXECUTIVE OFFICERIMEMBER I I <br />EXCLUDED? <br />N/A <br />""_ "'- <br />_-- _-- — <br />"""" <br />PER <br />STATUTE <br />--- <br />OTHER <br />E.L. EACI'I ACCIDENT <br />E.L. DISEASE — EA EMPLOYEE <br />(Mandatory In NH) <br />If yes, dascdbe undor <br />DESCRIPTION OF OPERATIONS below <br />E.L. DISEASE — POLICY LIMIT <br />MEDICAL PAYMENTS FOR PARTICIPANTS <br />PRIMARY MEDICAL <br />EXCESS MEDICAL <br />ERAAdditional amar s c e oo,may rsattac er I moreepcels require <br />CertlBed nstructorof:ZUMBA(R) <br />Tho csrtlilcgte holder Is added as an additional insured but only for liabili caused, it whole or in part, bZ the acts or omissions of the named Insured. <br />[N-'9:4Yf7L+L'VYEI11.L4]iN: <br />The City of Santa Ana and its of cers,employees,agents&representatives <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />Attn:Cormen Acosta, 1825 W. Civic Center <br />Santa Ana, CA 92701 <br />(OwnerlLessor of Premises) <br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE <br />WITH THE POLICY PROVISIONS, <br />AUTHORIZED REPRESENTATIVE <br />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 (2014101) The ACORD name and logo are registered marks of ACORD ©1988-2014 ACORD CORPORATION. All rights reserved, <br />