OSPINA, JUDITH 1A - 2011 - Laserfiche WebLink

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ACORDTM CERTIFICATE OF LIABILITY INSURANCE FDATE(MWDD/YYYY) TYPE OF INSURANCE 02/13/2012 HIS 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. HIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZE REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endo ed. If SU13 OGATION 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: Mass Merchandising K&K Insurance Group, Inc. 1712 Magnavox Way PHONE (A/C, No. Ext): 1-800-506-4856 AX (A/C, No): 1-260-459-5590 E-MAIL ADDRESS: info@fitnessinsurance-kk.com Fort Wayne IN 46804 INSURED 2000046870 CP# 2243 INSURER(S) AFFORDING COVERAGE NAIC # Judith R Ospina DBA: Js Dance Studio INSURERA: Nationwide Mutual Insurance Company 23787 INSURER B: /� 110 Tangelo 1 V l ` cc, �- - C. `- ' ER C: Irvine, CA 92618 FINURERD: Member of the Sports, Leisure & Entertainment RPG CnVFRAr;FS 1 00T101rw c w --..-___-- 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 O SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INS R LTR TYPE OF INSURANCE ADDL INSR SUBR WVD POLICY NUMBER POLICY EFF (MM/DD/YY) POLICY EXP (MM/DD/YY) LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY 6BRPG0000005155500 02/02/12 1:14 AM EDT 02/02/13 12:01 AM EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED CLAIMS -MADE FX7 OCCUR PREMISES Ea occurrence $300,000 MED EXP (Any one person) $5,000 PERSONAL & ADV INJURY $1,000,000 GENERAL AGGREGATE $3'000'000 PRODUCTS-COMP/OP AGG $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY r7 PROJECT r7LOC PROFESSIONAL LIABILITY $1,000,000 LEGAL LIAB TO PARTICIPANTS $1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS Ea Accident BODILY INJURY (Per person) BODILY INJURY (Per accident) X HIRED AUTOS NON -OWNED AUTOS Not provided while in Hawaii PROPERTY DAMAGE Per accident UMBRELLA LIAB OCCUR EXCESS LIAB CLAIMS - MADE p ' I ,•, `I .� .. _ . '' t. EACH OCCURRENCE AGGREGATE DED RETENTION WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/ - ,. �.. - OTH- WC TORY TORY LIMITS ER E.L. EACH ACCIDENT EXECUTIVE OFFICER/MEMBERN EXCLUDED? / A `. E.L. DISEASE - EA EMPLOYEE (Mandatory in NH) If yes, describe under E.L. DISEASE - POLICY LIMIT DESCRIPTION OF OPERATIONS below MEDICAL PAYMENTS FOR PARTICIPANTS PRIMARY MEDICAL EXCESS MEDICAL DESCRIPTION OF OPERATIONS I LOCATI NSI VEHICLES (Attach ACORD 101, Additional Remarks Schedule, IT more space is required) Certified Instructor of: Aerobics, Exercise, ZUMBA® The certificate holder is listed as an additional insured, but only With respect to the liability arising out of the operations of the insured named above. ***Void and replace certificate #2000041628*** Effective: 02/07/12-02/02/13 CERTIFICATE HOLDER �..._ _.. City of Santa Ana, Its officers, agents and employees SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED Parks, Recreation and Community Services Agency BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Attn: Donna Schultze ACCORDANCE WITH THE POLICY PROVISIONS. 1825 W Civic Center AUTHORIZED REPRESENTATIVE Santa Ana, 92701 Owner/Manager/Lessor er/Lessor of Premises 1 " r Coverage is only extended to U.S. events and activities. ** 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. ACORD 25 (2010/05) @ 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD