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FrancineR, Digitally signed by Francine <br />R. R. Villareal <br />Date: 2021.07.1915:58:04 <br />Villareal <br />CERTIFICATE OF LIABILITY INSURANCE DATE(MMI)o/YYYY) <br />05/26/2021 <br />TH S CERT F CATE IS SSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO R GHTS 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 />MPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If <br />SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this <br />certificate does not confer rights to the certificate holder In lieu of such endorsements . <br />PRODUCER <br />K&K Insurance Group, Inc. <br />1712 Magnavox WayINC,No <br />Fort Wayne IN 46804 <br />CONT TNAME: Mass Merchandising Underwrtbng <br />PN NE 1-800-506-4856 <br />Eat: Nc No: 1-260-459-5590 <br />ADDRESS: info@fitnessinsumnce-kk.com <br />PRODUCER <br />CUSTOMERID: <br />INSURER(S) AFFORDING COVERAGE <br />NNC4 <br />INSURED <br />INSURER A: Nationwide Mutual Insurance Company <br />23787 <br />Salomon Rivera <br />709 S. Parton St <br />Santa Ana, CA 92701 <br />INSURERS: <br />INSURER C: <br />INSURER D: <br />A Member of the Sports, Leisure & Entertainment RPG <br />!SURER E: <br />!SURER F: <br />COVERAGES CERTIFICATE NUMBER- WM9RRR19 DCTACrnu unaa000. <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 />INSD <br />R <br />MD <br />POLICY NUMBER <br />EFF <br />MMa1 <br />EXP <br />MMIDD/YYYY <br />LIMITS <br />A <br />X <br />COMMERCIAL GENERAL LIABILITY <br />CLAIMS. X OCCUR <br />MADE <br />X <br />BBRPG0000007446200 <br />06/01/2021 <br />12:01 AM EDT <br />06/012022 <br />12:01 AM <br />EACH OCCURRENCE <br />$1,000,000 <br />AMA E T D <br />PREMISES Ea Occurrence <br />$1,000,000 <br />MED EXP (Any one person) <br />$5,000 <br />PERSONAL&ADV INJURY <br />$1,000,000 <br />GENERALAGGREGATE <br />$5,000,000 <br />GEN'L <br />AGGREGATE LIMIT APPLIES PER: <br />POUCY OJEa ❑LOC <br />PRODUCTS—COMP/OPAGG <br />$1,000,000 <br />PROFESSIONAL LIABILITY <br />$1,000,000OTHER' <br />LEGAL LIAR TO PARTICIPANTS <br />$1,000,000 <br />AUTOMOBILE <br />LIABILITY <br />ANY AUTO <br />OWNED AUTOS SCHEDULED <br />ONLY AUTOS <br />NON -OWNED <br />AUTOS ONLY AUTOS ONLY <br />NOT PROVIDED WHILE IN HAWAII <br />N LIMIT <br />Eaccident <br />a <br />BODILY INJURY (Per parson) <br />BODILY INJURY (Per accident)HIRED <br />Per accident <br />UMBRELLAIJAB OCCUR <br />EXCESS LIAB CLAIMS -MADE <br />DEO P RETENTION <br />EACH OCCURRENCE <br />AGGREGATE <br />D <br />WORKERS COMPENSATION ANPER <br />EMPLOYERS' LIABILITY <br />ANY PROPRIETORIPARTNER/ YIN <br />EXECUTIVE OFFICER40u1EMBER <br />EXCLUDED?(Mandatory in NH) El <br />Ryes, describe under DESCRIPTION <br />OF OPERATIONS bebw <br />N/A <br />STATUffELJ OTHER <br />E.L EACH ACCIDENT <br />E.L DISEASE —EA EMPLOYEE <br />E.L DISEASE —POLICY LIMIT <br />MEDICAL PAYMENTS FOR PARTICIPANTS <br />PRIMARY MEDICAL <br />EXCESS MEDICAL <br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached! R 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 />LCR I IrMA 1 C MULUCK CANCELLATION <br />City of Santa Ana Risk Management Division <br />SHOULD ANY OF THE ABOVE DESCRIBED P L CIES BE CANCELLED BEFORE <br />20 Civic Center Plaza, 4th Floor <br />Santa Ana, CA 92702 <br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />AUTHORIZED REPRESENTATIVE <br />(Owner/Lessor of Premises) <br />Coverage is only extended to U.S. events and activi8es. <br />"NOTICE TO TEXAS INSUREDS: The Insurer for the purchasing group may not be subject to all the insurance laws and regulations of 1r` �MmWwd�sc` <br />[CREVIEW/®& APPROVEO BY: <br />ACORD 25 ( ) ©1988-2015 Al2016103 r�Y..n.e P. <br />t <br />The ACORD name and logo are registered marks of ACORD Risk Management Anaryst <br />