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ACORO® CERTIFICATE OF LIABILITY INSURANCE <br />DATE(MMIODNYYY) <br />12/19/2019 <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 ppoolicy((ies) must have ADDITIONAL INSURED provisions or be endorsed. <br />If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on <br />this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). <br />PRODUCER <br />CONTACT NAME: Mass Merchandising <br />K&K Insurance Group, Inc. <br />1712 Magnavox Way <br />Fort Wayne IN 46804 <br />FAX <br />aC No E:I: 1-800-648-6406 AIc w: 1-260-459-5940 <br />E-MAIL <br />ADDRESS: info@martialartsinsurance-kk.com <br />PRODUCER <br />CUSTOMER to, <br />INSURE S AFFORDING COVERAGE <br />NAIC# <br />INSURED 2001203257 CPq 3 <br />INSURER A: Nationwide Mutual Insurance Coirpary <br />23787 <br />Santiago Bautista <br />INSURER B: <br />DBA: Te-Kenjutsu-Kan Karate -Do <br />INSURER C: <br />2043 S. Birch <br />Santa Ana, CA 92707 <br />A Member of the Sports, Leisure & Entertainment RPG <br />INSURER D: <br />INSURER E: <br />INSURER F: <br />COVERAGES CERTIFICATE NUMBER: 2000452104 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 />INSfl <br />LTR <br />TYPE OF INSURANCE <br />ADDL <br />IlSD <br />SUER <br />wVD <br />POLICY NUMBER <br />POLICY EFT <br />MMDDIYYY <br />POLICY EXP <br />MWDDNYYY <br />LIMITS <br />A <br />X <br />COMMERCIAL GENERAL LIABILITY <br />CLAIMS-MAOEFX]OCCUR <br />X <br />SBRPG0000007213900 <br />01/01/20 <br />12:01 AM <br />01/01/21 <br />12:01 AM <br />EACH OCCURRENCE <br />$1,000,000 <br />DAMAGE TORENTED <br />PREMISES(EaO=.I <br />$1•000.ODO <br />LIED EXP I" ore, person) <br />$5,000 <br />PERSONAL B ADV INJURY <br />$1,000,000 <br />GEN'L AGGREGATE UMIT APPLIES PER: <br />POLICY E PROJECT LOG <br />OTHER: <br />GENERAL AGGREGATE <br />$5,000,000 <br />PRODUCTS -COMPNP AGO <br />$1,000,000 <br />PROFESSIONAL LIABILITY <br />$1,000.000 <br />LEGAL LIAR TO PARTICIPANTS <br />$1,000,000 <br />AUTOMOBILE <br />XI <br />X <br />LIABILITY <br />AUTO <br />OWNED SCHEDULED <br />AUTOS ONLY AUTOS <br />HIRED NON -OWNED <br />AUTOS ONLY AUTOS ONLY <br />Not provided while in Hawaii <br />amdant <br />BODILY INJURY (Per Person) <br />BODILY IWURY(P. amders) <br />PROPERTY DAMAGE <br />Per acadent <br />UAB OCCUR <br />EXCESS UAB CLAIMS -MADE <br />DED RETENTION <br />EACH OCCURRENCE <br />AGGREGATE <br />WORKERS COMPENSATION <br />AND EMPLOYERS' LIABILITY <br />ANYPROPRIETORPARTNEW YIN <br />EXECUTIVE OFFICERIMEMBER <br />EXCLUDED? (Mandatory In Nit <br />H yes bombe ur ee <br />DESCRIPTION OF OPERATIONS Delon <br />N/A <br />PERSTA OTHER <br />EL EACH ACCIDENT <br />El. DISEASE - EA EMPLOYEE <br />E.L DISEASE -POLICY UNIT <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 De anapMred If more space Is required) <br />RE: Martial Arts Instructor <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 />City of Santa Ana RISK Management UIvlsion SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE <br />20 Civic Center EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH <br />Santa Ana, CA 92701 THE POLICY PROVISIONS. <br />Owner/ManagerlLessorof Premises Ev WED & APPRO EBt° <br />flQED REPRESENTATIVE <br />By R k MANAGEMENT Divi iW.� <br />4JAN 3 0 2020 C 1988-2015 ACORD CORPORATION. All rights reservec <br />S.A ANTHA M. LAMBERT <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 (2016/03) The ACORD name and logo are registered marks of ACORD <br />