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FrancineR, Digitally signed by Francine <br />R. R. Villareal <br />Villareal Date: 2021.07.1915:58.04 <br />.Arun' <br />"`� CERTIFICATE OF LIABILITY INSURANCE DAM MM0DNYYYJ <br />0512612021 <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 REPRESENTATIVE <br />OR PRODUCER, AND THE CERTIFICATE HOLDER. <br />IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the po icy(jes) must have ADDITIONAL INSURED provisions or be endorsed. If <br />SUBROGATION IS WAIVEDsubject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this <br />certificate does not confer i rhts to the certificate holder in lieu of such endorsements . <br />PRODUCER <br />CONTACT NAME: Mass Merchandising UndeWyfRing <br />K&K Insurance Group, Inc. <br />1712 Magnavox Way <br />Fort Wayne IN 46804 <br />PN NE <br />NoNo at): 1-800-506-4656 p/C Ne; 1-260-459-5590 <br />ADDRESS: info@rdnessinsurance-kk.com <br />MUuUQLH <br />CUSTOMER ID: <br />INSURER(S) AFFORDING COVERAGE <br />NAIC# <br />INSURED <br />INSURER A: Nationwide Mutual Insurance Company <br />23787 <br />Salomon Rivera <br />INSURER B: <br />709 S. Parton St <br />Santa Ana, CA 92701 <br />INSURERC: <br />INSURER D: <br />A Member of the Sports, Leisure & Entertainment RPG <br />INSURER E: <br />INSURER F: <br />COVERAGES CERTIFICATE NUMBER: W01955619 RFVI.CInm NIIMIRFR- <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 />TYPE OF INSURANCE <br />ADDL <br />INSO <br />UBR <br />WVO <br />pODCY NUMBER <br />P F <br />MMIO <br />POLICY <br />MMIDD/YYYY <br />UNITS <br />A <br />X <br />COMMERCIAL GENERAL LIABILITY <br />MADE OCCUR <br />X <br />6BRPG000OD07446200 <br />06/01/2021 <br />12:01 AM EDT <br />06/01/2022 <br />12:01 AM <br />EACH OCCURRENCE <br />$1,000,000 <br />DAMA <br />PREMISES Ea Ocwnence <br />$ 1,000,000 <br />GEN'L <br />MED UP(Any one person) <br />$5,000 <br />PERSONAL &ADV INJURY <br />$1.000.000 <br />GENERAL AGGREGATE <br />$5,000,000 <br />AGGREGATE LIMIT APPLIES PER <br />POLICY PRO- <br />JECT LOC <br />OTHER: <br />PRODUCTS—COMP/OP AGG <br />$1,000,000 <br />PROFESSIONAL LIABILITY <br />$1,000,000 <br />LEGAL LIAR TO PARTICIPANTS <br />$1,000,000 <br />AUTOMOBILE <br />LIABILITY <br />ANY AUTO <br />OWNED AUTOS SCHEDULED <br />ONLY LJ AUTOS <br />HIRED NON -OWNED <br />AUTOS ONLY AUTOS ONLY <br />NOT PROVIDED WHILE IN HAWAII <br />COMBINED SINGLE L M <br />Ea accident <br />BODILY INJURY (Per persen) <br />BODILY INJURY(Peraccident) <br />Per accident <br />UMBRELLA DAB OCCUR <br />EXCESS LIAR CLAIMS -MADE <br />DELI RETENTION <br />EACH OCCURRENCE <br />AGGREGATE <br />WORKERS COMPENSATION AND <br />EMPLOYERS' LIABILITY <br />ANYPROPRIETOR/PARTNEW Y/N <br />EXECUTIVE OFFICERIMEMBER ❑ <br />EXCLUDED? (Mandatory in NH) <br />Ryes, desodba under DESCRIPTION <br />OF OPERATIONS below <br />NIA <br />PER <br />STATUTE OTHER <br />E.L EACH ACCIDENT <br />E.L DISEASE —EA EMPLOYEE <br />E.L DISEASE—POUCV LIMIT <br />MEDICAL PAYMENTS FOR PARTICIPANTS <br />PRIMARY MEDICAL <br />EXCESS MEDICAL <br />DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be atFachad if more space is required) <br />Non -certified Instructor of. Salsa <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 />CERTIFICATE HOLDER CANCELLATION <br />City of Santa Ana Risk Management Division <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />20 Civic Center Plaza, 4th Floor <br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />Santa Ana, CA 92702 <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />AUTHORIZED REPRESENTATIVE <br />(Owner/Lessor of Premises) <br />Coverage is only extended to U.S. events and activities. lrMto <br />"NOTICE TO TEXAS INSUREDS: The Insurer for the purchasing group may not be subject to all the insurance laws and regulations of a Risk <br />l+q <br />REV isle marlagenlerdDtliatlm <br />® APPRCNB1n <br />p4m r nee P, vd� <br />ACORD 2E (2016103) ©1988-2016 A <br />The ACORD name and logo are registered marks of ACORD l Risk Management Analyst <br />