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DocuSign Envelope ID:6647E338-085A-4D3E-B45C-6D9ECB0533C1 <br /> I <br /> ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)08/04/2015 <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 INSURER(S), 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 erwr g <br /> K&K Insurance Group, Inc. PHONE: 1-800-506-4856 FAX:(A/C,No): 1-260-459-5590 <br /> 1712 Magnavox Way (A/c,No.Ext). <br /> E-MAIL info@fitnessinsurance-kk.com <br /> Fort Wayne IN 46804 ADDRESS: <br /> INSURER(S)AFFORDING COVERAGE NAIC# <br /> INSURER A: Nationwide Mutual Insurance Company 23787 <br /> INSURED INSURER B: <br /> Functional Fitness, LLC INSURER C: <br /> 605 Eastowne Drive, Suite C INSURER D: <br /> Chapel Hill, NC 27514 INSURER E: <br /> A Member of the Sports,Leisure&Entertainment RPG INSURER F: <br /> COVERAGES CERTIFICATE NUMBER:W00677958 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 /> INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS <br /> LTR INSD WVD (MM/DD/YY) (MM/DD/YY) <br /> A X COMMERCIAL GENERAL LIABILITY X 6BRPG0000005690300 08/21/2015 08/21/2016 EACH OCCURRENCE $1,000,000 <br /> 12:01 AM EDT 12:01 AM DAMAGE TO RENTED <br /> CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $300,000 <br /> MED EXP(Any one person) $5,000 <br /> PERSONAL&ADV INJURY $1,000,000 <br /> GEN';AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE <br /> $5,000,000 <br /> POLICY PRO- X LOC PRODUCTS-COMP/OP <br /> JECT $1,000,000 <br /> OTHER PROFESSIONAL LIABILITY $1,000,000 <br /> LEGAL LIAB TO PARTICIPANTS $1,000,000 <br /> A AUTOMOBILE LIABILITY 6BRPG0000005690300 08/21/2015 08/21/2016 COMBINED SINGLE LIMIT $1,000,000 <br /> 12:01 AM EDT 12:01 AM (Ea Accident) <br /> ANY AUTO BODILY INJURY(Per person) <br /> ALL OWNED AUTOS SCHEDULED BODILY INJURY(Per accident) <br /> AUTOS <br /> X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE <br /> — AUTOS (Per accident) <br /> X Not provided while in Hawaii <br /> UMBRELLA LIAB OCCUR EACH OCCURRENCE <br /> EXCESS LIAB CLAIMS-MADE AGGREGATE <br /> -DED nRETENTION <br /> WORKERS COMPENSATION PER (OTHER <br /> AND EMPLOYERS'LIABILITY Y/N STATUTE <br /> ANY PROPRIETORSHIP/PARTNER/ E.L.EACH ACCIDENT <br /> EXECUTIVE OFFICER/MEMBER <br /> EXCLUDED? N/A E.L.DISEASE–EA EMPLOYEE <br /> (Mandatory in NH) <br /> If yes,describe under E.L.DISEASE–POLICY LIMIT <br /> DESCRIPTION OF OPERATIONS below <br /> MEDICAL PAYMENTS FOR PARTICIPANTS PRIMARY MEDICAL <br /> EXCESS MEDICAL <br /> DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) <br /> Various offsite locations <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,NC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br /> 200 S.Cameron St., P.O. Box 8181 THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE <br /> Hillsborough, NC 27278 WITH THE POLICY PROVISIONS. <br /> (Owner/Lessor of Premises) 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 />