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DocuSign Envelope ID:6EE6AC2A-3229-41 BE-82D3-E6B107B201A2 <br /> ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE(MWDD/YYYY) <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), AUTHORIZES <br /> REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER. <br /> IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. if SUBROGATION IS WAIVED,subject to the <br /> terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the <br /> certificate holder in lieu of such endorsement(s). <br /> PRODUCER CONTACT <br /> NAME; Mass Merchandising Underwriting <br /> K&K Insurance Group, Inc. PHONE: <br /> 1712 Magnavox Way aC No.Ext: 1-800-506-4856 Fax:(aC,No): 1-260-459 5590 <br /> Fort Wayne IN 46804 E-MAIL info@fitnessinsurance-kk.com <br /> @fitnessinsurance-kk.com <br /> INSURER(S)AFFORDING COVERAGE NAIC# <br /> INSURED INSURER A: NatlonWide Mutual Insurance Com an 3787 <br /> W NSURER B: <br /> William J Meyers NSURER C: <br /> 1204 Little Creek Road <br /> Durham,NC 27713 NSURER D: <br /> A Member of the Sports, Leisure&Entertainment RPG NSURER E: <br /> NSURER F: <br /> COVERAGES CERTIFICATE NUMBER:W005 '2260 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 /> NSR TYPE OF INSURANCE ADD L SUER <br /> LTR INSD WVD POLICY NUMBER POLICY EFF POLICY EXP <br /> MWDDNY MWDD/YY LIMITS <br /> A FGEN';AGGREGATE MMERCIAL GENERAL LIABILITY 6BRPG0000005527100 12/31/2014 12/31/2015 EACH OCCURRENCE <br /> 12:01 AM ED 12:01 AM DAMAGE TO RENTED $$300,00C <br /> CLAIMS-MADE a OCCUR $300,00( <br /> PREMISES Ea occurrence _ <br /> MED EXP(Any one person) $5,000 <br /> PERSONAL&ADV INJURY $1,000,OOC <br /> LIMIT APPLIES PER: GENERAL AGGREGATE <br /> PRO- 5 000 OOC <br /> JECT ❑ LOC <br /> PRODUCTS-COMP/OP AGG <br /> OTHER $1,000,00( <br /> PROFES 31ONAL LIABILITY $1,000,00( <br /> LEGAL LIAB TO PARTICIPANTS $1,000,00( <br /> AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT <br /> ANY AUTO Ea Accident <br /> SCHEDULED BODILY INJURY(Per person) <br /> ALL OWNED AUTOS BAUTOS BODILY INJURY(Per accident) <br /> HIRED AUTOS NON-OWNED <br /> AUTOS PROPERTY DAMAGE <br /> Not provided while in Hawaii Per accident <br /> UMBRELLA LIAB OCCUR <br /> EXCESS LIAB CLAIMS-MADE EACH OCCURRENCE <br /> DED RETENTION <br /> AGGREGATE <br /> WORKERS COMPENSATION <br /> AND EMPLOYERS'LIABILITY Y/N PER OTHER <br /> ANY PROPRIETORSHIP/PARTNER/ STATUTE <br /> EXECUTIVE OFFICER/MEMBER E.L.EACH ACCIDENT <br /> EXCLUDED? N/A <br /> (Mandatory In NH) E.L.DISEASE—EA EMPLOYEE <br /> If yes,describe under <br /> DESCRIPTION OF OPERATIONS below E.L.DISEASE—POLICY LIMIT <br /> MEDICAL PAYMENTS FOR PARTICIPANTS <br /> PRIMARY MEDICAL <br /> EXCESS MEDICAL <br /> SCR IO O OPERATIONS VEHICLES(ACORD D ,Additional Remarks c e u e,may a attached t more spaces required) <br /> Abuse,Molestation, Harassment or Sexual Conduct Defense Cost Reimbursement—Limit$100,000 <br /> Non-certified Instructor of:Tai Chi <br /> CERTIFICATE HOLDER CANCELLATION <br /> Evidence of Coverage SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br /> THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE <br /> WITH THE POLICY PROVISIONS. <br /> AUTHORIZED REPRESENTATIVE <br /> Coverage is only extended to U.S.events and activities. <br /> '*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 <br /> ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD ©1988-2014 ACORD CORPORATION. All rights reserved. <br />