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DocuSign Envelope ID:43E9B846-09E2-4994-94AC-BO9174436B31
<br /> ACORD,,, CERTIFICATE IMMlDD1YYYY}
<br /> CERTIFICATE OF LIABILITY INSURANCE 07!2712015
<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), AUTHORIZED
<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 Mass Merchandising Underwriting
<br /> g
<br /> K&K Insurance Group, Inc. PHONE: 1-800-648-6406 FAX:(A/C,No): 11-260-459-5940
<br /> 1712 Magnavox Way
<br /> IA/G, Ext
<br /> E-MAIL
<br /> Fort Wayne IN 46804 gpbRESS: info@martialartsinsurance-kk.com
<br /> INSURER(S)AFFORDING COVERAGE NAIC At
<br /> INSURER A: Nationwide Mutual Insurance Company 23787
<br /> INSURED INSURER B:
<br /> Society for the Betterment of the Human Condi INSURERC:
<br /> DBA; Ligo Dojo of Budo Karate INSURER D:
<br /> 2518 A Millwood Court INSURER E:
<br /> Chapel Hill, NC 27514
<br /> A Member of the Sports, Leisure&Entertainment RPG INSURER F:
<br /> COVERAGES CERTIFICATE NUMBER:W00673865 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 RFSPECT 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 ADDL SUBR POLICY EFF POLICY EXP
<br /> LTR TYPE OF INSURANCE INSD VV POLICY NUMBER MMIDDIYY MMIDDIYY LIMITS
<br /> A X COMMERCIAL GENERAL LIABILITY X 6BMAS0000005704200 07/27/2015 07/2712016 EACH OCCURRENCE $1,000,000
<br /> CLAIMS-MADE OCCUR 10:51 PM ED 12:01 AM DAMAGE TO RENTED $500,000
<br /> PREMISES Ea occurrence
<br /> MED EXP(Any one person) $5,000
<br /> PERSONAL&ADV INJURY $1,()00,000
<br /> I
<br /> GENERAL AGGREGATE j
<br /> GEN';AGGREGATE LIMIT APPLIES PER:
<br /> $5.()()%00
<br /> OOC
<br /> POLICY ❑ PRO- LOC PRODUCTS-COMP/OP AGG
<br /> JECT $1,000,OOC
<br /> OTHER PROFESSIONAL LIABILITY $1,000,000
<br /> LEGAL LIAR TO PARTICIPANTS $1,000,00C
<br /> A AUTOMOBILE LIABILITY 6BMAS0000005704200 07/27/2015 07/27/2016 COMBINED SINGLE LIMIT $1,500,000
<br /> 10:51 PM EDT 12:01 AM Ea Accident
<br /> ANY AUTO BODILY INJURY(Per person)
<br /> ALL OWNED AUTOS SCHEDULED BODILY INJURY(Per accident) j
<br /> AUTOS
<br /> X MIRED AUTOS X NON-OWNED PROPERTY DAMAGE
<br /> AUTOS Per acciden# j
<br /> X Not provided while in Hawaii
<br /> UMBRELLA LIAR OCCUR EACH OCCURRENCE
<br /> i
<br /> EXCESS LIAR H CLAIMS-MADE AGGREGATE
<br /> ❑ED RETENTION
<br /> WORKERS COMPENSATION PER OTHER
<br /> AND FMPLOYVRS'LIABILITY YIN S7A7UTE
<br /> ANY PROPRIETORSHIPIPARTNERI EL.EACH ACCIDENT
<br /> EXECUTIVE OFFICERIMEMl3ER LA EXCLUDED? NIA E.L.DISEASE--EA EMPLOYEE
<br /> {Mandatory In NH)
<br /> If yes,describe under E.L.DISEASE—POLICY LIMIT
<br /> DESCRIPTION OE OPERATIONS below
<br /> A MED€CAL PAYMENTS FOR PARTICIPANTS 6B MAS0000005704200 1 07/2712015 07/27/2016 PRIMARY MEDICAL
<br /> 10:51 PM EDT 12:01 AM EXCESS MEDICAL
<br /> $150,000
<br /> DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
<br /> Sexual Abuse or Sexual Molestation Liability-$1,000,000 each occurrence(included above)/$1,000,000 aggregate(included above)
<br /> Location#1:630 Weaver Dairly Rd,Suite 107,Chapel Hill, North Carolina 27514; Location#2:2518 A Millwood Court,Chapel Hill,North Carolina 27514
<br /> Martial Arts styte(s): Karate;Birthday parties
<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 /> Orange County SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br /> 200 S. Cameron Street, PO Box 8181 THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE
<br /> Hillsoborough, NC 27278 WITH THE POLICY PROVISIONS.
<br /> (Co-promoter) 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(2014101) The ACORD name and logo are registered marks of ACORD ©1988-2014 ACORD CORPORATION. All rights reserved.
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