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.4►coR©0 CERTIFICATE OF LIABILITY INSURANCE DA02/26/2025`t THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement, A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Gene-Marc Athletic Insurance Agency#OE67789 PHONE (800)247-1734 FAX No 6301 Southwest Boulevard,Suite 101 E-MAIL contact@bene-marc.com ADDRESS: Fort Worth.Texas 76132 INSURERS AFFORDING COVERAGE NAIC# INSURER A: HDI Global Specialty SE AA-112CB22 INSURED INSURER 8: AXIS Global Accident&Health Insurance Company 37273 Southern California Municipal Athletic Federation(SCMAF) PO Box 3605 INSURER C South El Monte,CA 91733 INSURER D: SCMAF Member: Martin Torres-Karate Do Kiai INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 9066-55782 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBRI POLICY EFF POLICY EXP LTR TYPE OF INSURANCE WVD POLICY NUMBER MMIDDIYYYY MMIDDIYYYY LIMITS COMMERCIAL GENERAL LIABILITY I I EACH OCCURRENCE S 1,000,000.00 18LB7323 01/0112025 0110112026 DAMAGE RENTED CLAINIS-MADE ®OCCUR PREMISES Ea occurrence 5 100.,000.00 MED EXP(Any one person) S 5,000.00 A X X Abuse&Molestation PERSONAL aADVINJURY 5 1,000.,000.00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 5 5,000,000.00 POLICY❑ PEC7 ❑ Loc 1,000,000 Occ.12,000,000 Agg. PRODUCTS-cOMProPacc 5 1,000,000.00 OTHER: Participant Liability S 1,000,000.00 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S Ea accident _ ANY AUTO BODILY INJURY tPer person) S OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) S HIRED NON-CMIED PROPERTY DAMAGE S AUTOS ONLY AUTOS ONLY Par ac-udent 5 UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE S DED I I RETENTIONS S WORKERS COMPENSATION STATUTE 01 ANDEMPLOYERS'LIABILITY YIN ANYPROPRIETORIPARTNERIEXECUTIVE OFFICERWEMMBEREXCWDED9 NIA E.L..EACHACCYDENT S (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 3 B Participant Accident Medical SRPO-50256-243 01101/2025 01101/2026 Deductible: $0.00 Limit: $5,000.0C DESCRIPTION OF OPERATIONS I LOCATIONS f VEHICLES(ACORD 101.Additional Remarks Schedule,may be attached if more space is required) This policy includes a blanket additional insured endorsement that provides additional insured status to the cartiticate heltler per form GG 20 26 07 04. The General Liability policy contains Primary and Non Contributory wording per endorsement E1602AJ-1112_The General Liability policy contains an endorsement for Waiver of Transfer of Rights of Recovery Against Others to Us per attached form CG 24 04 05 09.City of Santa Ana entity.it's officers.officials agents and it's volunteers are additional insured. TU Tran Digitally signed by Tu Tran Nguyen Coverage for SCMAF member approved activities for which a premium is paid and reported to the Company. Date:202503,17 Nguyen s1-a7'oo° SCMAF Member: Martin Torres-Karate Do Kiai Coverage is limited to the following activity dates: 02126125-12/31/25 APPROVED CERTIFICATE HOLDER CANCELLATION By Tu Tran Nguyen at 3:41 pm,Mar 17, 2025 City of Santa Ana SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Attention:Parks,Recreation,and Community Services Agency THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 20 Civic Center Plaza M-23 AUTHORIZED REPRESENTATIVE Santa Ana,CA 92702 Alisa Lynn Hall � ! 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD