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AcoRO' CERTIFICATE OF LIABILITY INSURANCE <br />F ATE(MWODIYYYY) <br />01/15/2020 <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 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 />K&K Insurance Group, Inc. <br />1712 Magnavox Way <br />Fort Wayne IN 46804 <br />CONTACTNAME: Mass Merchondlsin <br />FAX <br />Ac Exit: t-800.648-6406 AC.NI: 1-260-459-5940 <br />E-MAIL <br />ADDRESS: info@danceinsurance-kk.com <br />PRODUCER <br />CUSTOMER to: <br />INSURERS AFFORDING COVERAGE <br />I NAIL• <br />INSURED 2001208775 CP# 75 <br />Salomon Rivera <br />709 S. Parton St <br />Santa Ana, CA 92701 <br />A Member of the Sports, Leisure & Entertainment RPG <br />INSURER A: Nationwide Mutual Insurance Company <br />23787 <br />INSURER 8: <br />INSURER C: <br />INSURER D: <br />INSURER E: <br />INSURER F: <br />COVERAGES CERTIFICATE NUMBER: 2000454229 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 />ADDL <br />RISD <br />SUBR <br />WVD <br />POLICY NUMBER <br />POLICY EFF <br />WDDIYVY <br />POLICY UP <br />MWDD/YYYY <br />LMRS <br />A <br />X <br />COMMERCIAL GENERAL uABILrrV <br />X <br />6BRPG0000007214200 <br />01106M <br />01/OW1 <br />EACH OCCURRENCE <br />$1,D00,000 <br />CLAM.iSMADE F OCCUR <br />2:34 PM EDT <br />12.01 AM <br />DAMAGE TO RENTED <br />PREMISES Ee Ocaxao n <br />$1,000,OOD <br />MED EXP (AA, one person) <br />$5,0130 <br />PERSONAL& ADVINJURY <br />$1,000,000 <br />GENL AGGREGATE LIMIT APPLIES PER: <br />GENERALAGGREGATE <br />$5,000,D00 <br />POLICY PROJECT LOC <br />PRODUCTS-COMPIOP AGG <br />$1,000,000 <br />PROFESSIONAL LABILITY <br />$1,000,000 <br />OTHER: <br />LEGAL UAB TO PARTICIPANTS <br />$1,OD0,0D0 <br />AUTOMOBILE UAIRUTY <br />CCNSlI <br />accident <br />ANY AUTO <br />BODILY INJURY (Per pxson) <br />OWNED SCHEDULED <br />AUTOSONLY AUTOS <br />HAUTOSONLY <br />BODILY INJURY (Per acddan) <br />HIRED NON -OWNED <br />PROPERTY DAMAGE <br />AUTOS ONLY <br />Per acodenl <br />X Not provided while in Hawaii <br />UMBRELLA <br />IIAB OCCUR <br />EACH OCCURRENCE <br />AGGREGATE <br />EXCESS LIAR CLAIMS -MADE <br />DED RETEN7]ON <br />WORKERS COMPENSATION <br />AND EMPLOYERS' LIABILITY <br />WA <br />PERSTATUTE OTHER <br />ANY PROPRIETORPARTNERV YIN <br />E.L EACH ACCIDENT <br />EXECUTIVE OFFICERVEM1BER <br />EXCLUDED' (Mandatory In Nip r_1 <br />EL DISEASE -EA EMPLOYEE <br />It yes describe under <br />DESCRIPTION OF OPERATIONS below <br />E.L DISEASE -POLICY UNIT <br />MEDICAL PAYMENTS FOR PARTICIPANTS <br />PRIMARY MEDICAL <br />234 PM EDT <br />EXCESS MEDICAL <br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORO 101, Additional Remarks Schedule, may be altache4 It more speoe M required) <br />Non -Certified Instructor of: Salsa <br />City of Santa Ana, officers, agents, employees and volunteers are added as an additional insured, but only for liability caused, in whole or in part, by the acts or <br />omissions of the named insured. <br />"This certificate voids and replaces certificale # W01658334" <br />CERTIFICATE HOLDER CANCELLATION <br />City of Santa Ana Risk Management Division <br />20 Civic Center Plaza <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE <br />EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH <br />Santa Ana, CA 92702 <br />THE POLICY PROVISIONS. <br />Owner/Manager/Lessor of Premises <br />AUTHORIZED REPRESENTATIVE <br />-/,- � REV EWED & APPROVE <br />©1988.2015 ACOTgM <br />N 22 2020 <br />Coverage is only extended to U.S. events and activities. IaA M I AM <br />NOTICE TO TEXAS INSUREDS: The Insurer for the purchasing group may not be subject to all the insurance lawe fate 0 exas. <br />ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD <br />