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ACORD„ CERTIFICATE OF LIABILITY INSURANCE DAT2/1112015 Y) <br />02/11/2015 <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(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 8eu of such endorsements . <br />PRODUCER <br />NAMEE: <br />Mass March Underwriting <br />K&K Insurance Group, Inc. <br />1712 Magnavox Way <br />Fort Wayne Indiana 46804 <br />Y <br />PHONE, <br />A/C No, Est: <br />8BB-580-8041 <br />FAX:(A1C,No): <br />260-459-5995 <br />E-MAIL <br />AggRESS: <br />info fitnesslnsurance-kk.com <br />@ <br />INSURER(S) AFFORDING COVERAGE <br />NAIC M <br />INSURER A: <br />Nationwide Mutual Insurance Company <br />23787 <br />INSURED <br />INSURER e: <br />Mafia L Madrigal <br />2530 W Hood Ave <br />Santa Ana, CA 92704 <br />A Member of the Sports, Leisure & Entertainment REG <br />INSURER Co <br />INSURER D: <br />INSURER E: <br />INSURER F: <br />GU 1BRAGES CERTIFICATE NUMBER: W00589699 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 />TYPE OF INSURANCE <br />ADOL <br />INSD <br />SUBR <br />WVD <br />POLICY NUMBER <br />POLICY CFF <br />MMIDDM <br />POUCYEXP <br />MMIDDNY <br />LIMITS <br />A <br />X <br />COMMERCIAL GENERALI�LI <br />X <br />6BRP00000005515500 <br />02(13/201.5 <br />02/13/2016 <br />EACH OCCURRENCE <br />$1,000,00 <br />(ABILITY <br />CLAIMS -MADE I% OCCUR <br />LJ <br />12:01 AM EDT12:01 <br />AM <br />DAMAGET RRENTED <br />PREMISES fEa occurrence <br />$500,000 <br />MED EXP IAny one person) <br />$10.000 <br />PERSONAL& ADV INJURY <br />$1,000,00 <br />GEN', AGGREGATE LIMIT APPLIES PER: <br />GENERAL AGGREGATE <br />POLICY ❑ PRO- ❑ LOC <br />JECT <br />5 000 00 <br />PRODUCTS-COMPIOPAGG <br />1 000,00 <br />PROFESSIONAL LIABILITY <br />$1,000,00 <br />OTHER <br />LEGAL LIAR TO PARTICIPANTS <br />$11000,00 <br />AUTOMOBILE LIABILITY <br />COMBINED SINGLE LIMIT <br />Ea Accldenl <br />BODILY INJURY (Per person) <br />ANYAUTO <br />SCHEDULED <br />ALLOWNEDAUTOS <br />BODILY INJURY (Per accaenq <br />ON -OWNED ED <br />HIRED AUTOS E3UTOB <br />PROPERTY QAMAGE <br />Per accident) <br />Not provided vfiile, in Hawaii <br />UNU RELLA UAB OCCUR <br />EACH OCCURRENCE <br />EXCESS LIAB CLAIMS -MADE <br />AGGREGATE <br />DEQ I RETENTION <br />WORKERS COMPENSATION <br />AND EMPLOYERS' LIABILITY YIN <br />ANY PROPRIETORSHINPARTNERI = <br />EXECUTIVE DFFICEWMEMBER <br />EXCLUDED? <br />N / A <br />PER <br />STATUTE <br />OTHER <br />E.L. EACH ACCIDENT <br />E.L DISEASE - EA EMPLOYEE <br />(Mandatary in NH1 <br />If yo%denone uodar <br />DESCRIPTION OF OPERATIONS bolo- <br />El, DISEASE - POLICY LIMIT <br />MEUIGAL PAYMENTS FOR PARTICIPANTS <br />PRIMARY MEDICAL <br />EXCESS MEDICAL <br />SCRIPTION OF GPERAhON5r1TTXr1MrV54ICIACONO id , Additional Remarks c a u e, map attar a ,mere space In required) <br />Certified In Ct00,r of: Aerobics, Dance, ZUMBA@ <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 />f:ER I R•R:A I E MULUEK 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 @ 1988.2014 ACORD CORPORATION. All rights 2 <br />served. <br />