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DocuSign Envelope ID: CE03F77E-2613-496A-9C6E-Fll685DF6CDA <br /> K&K Insurance Group,Inc. <br /> 1712 Magnavox Way <br /> Fort Wayne,IN 46804 <br /> .... Phone 1-800-506-4856 <br /> Insuring the wo lTs fanI Claims 1-800-237-2917 <br /> i <br /> Application Date : 07/31/2015 <br /> MEN= e • <br /> ,Are you an insurance agent or No <br /> broker? <br /> Named insured (as it should appear Nathaniel P Shapiro <br /> on the policy): <br /> Doing business as (DBA): nat Shapiro <br /> Contact first name: <br /> Contact last name: <br /> Mailing address: 2701 homestead rd. <br /> City: chapel hill State: North Carolina Zip: 27516 <br /> Phone: 919-357-5392 Fax: Cell: 9-357- <br /> 5 53392 <br /> E-mail: natshapiro89 @gmail.com <br /> Website: <br /> This is a new account <br /> Eliglb1hty <br /> Selected operation(s): Personal training <br /> Coverage effective date(s): 09/01/2015 to <br /> 09/01/2016 <br /> In which state does the insured reside? North Carolina <br /> Does the insured employ other people? No <br /> Is the insured under the age of 18? No <br /> F <br /> Is the insured currently certified? Yes <br /> Who is the insured certified by? <br /> NASM <br /> Coverage&.,L mits <br /> Each Occurrence: $ 1,000,000 <br /> 5,000,000 <br /> General Aggregate (other than Products-completed Operations): $ (per year) <br /> Products-completed Operations Aggregate: $ 1,000,000 <br /> Personal and Advertising Injury: $ 1,000,000 <br /> Legal Liability to Participants: $ 1,000,000 <br /> Professional Liability: $ 1,000,000 <br /> Damage to Premises Rented to You: $ 300,000 <br /> I <br /> Medical Expense (other than participants): $ 5,000 <br /> Abuse, Molestation, Harassment or Sexual Conduct Defense Cost $ 100,000 <br /> Reimbursement <br /> i <br />