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DocuSign Envelope ID:593338F8-59C1-4A9D-92DC-A91318C543A3 <br /> 4„, , _,„ <br /> .., ., = K&K Insurance Group,Inc. <br /> 1712 Magnavox Way <br /> Fort Wayne,IN 46804 <br /> Phone 1-800-506-4856 <br /> -. N'kS"liY t"/ `O' Fax 1-260-459-5590 <br /> Insuring ib r world's feint Claims 1-800-237-2917 <br /> Application Date : 07/31/2015 <br /> 7 s t Ns; Fina��-Surnnle x <br /> 5 L e - i 7 <br /> tE Fitness Instructors, <br /> _ <br /> -;Insured Information <br /> 2 <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: 1. <br /> Mailing address: 2701 homestead rd. <br /> City: chapel hill State: North Carolina Zip: 27516 <br /> Phone: 919-357-5392 Fax: Cell: 919-357- <br /> 5392 <br /> E-mail: natshapiro890gmaii.com t <br /> is <br /> Website: <br /> This is a new account <br /> Commercial General,Liability _ <br /> Eligibility <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 /> Is the insured currently certified? Yes <br /> Who is the insured certified by? <br /> NASM <br /> Coverage&.Limits <br /> Each Occurrence: $ 1,000,000 <br /> 5,000,000 <br /> General Aggregate (other than Products-completed Operations): $ (per year) 1 <br /> Products-completed Operations Aggregate: $ 1,000,000 i <br /> Personal and Advertising Injury: $ 1,000,000 i= <br /> Legal Liability to Participants: $ 1,000,000 <br /> Professional Liability: $ 1,000,000 <br /> Damage to Premises Rented to You: $ 300,000 <br /> Medical Expense (other than participants): $ 5,000 <br /> Abuse, Molestation, Harassment or Sexual Conduct Defense Cost $ 100'000 <br /> Reimbursement <br />