2017-257-E Aging - Arlene Bynum-Mills for wellness instruction

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DocuSign Envelope ID:D2C76CFB-8982-463E-ABA8-98FE7C445551 AcoRD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 04/30/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER - CONTACT NAME: Mass Merchandising Underwriting K&K Insurance Group,Inc. PHONE 1-800-506-4856 FAX 1-260-459-5590 1712 Magnavox Way E-MAILo ,Ext): (A/c,No): Fort Wayne IN 46804 ADDRESS: info @fitnessinsurance-kk.com PRODUCER CUSTOMER ID: INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: Nationwide Mutual Insurance Company 23787 Arlene Bynum INSURER B: DBA:Arlene Bynum INSURER C: 213 Rosaline Lane Durham,NC 27713 INSURER D: A Member of the Sports,Leisure&Entertainment RPG INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: W01021108 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD (MM/DD/YYYY) (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY 6BRPG0000006028600 05/01/2017 05/01/2018 EACH OCCURRENCE $1,000,000 CLAIMS- X OCCUR 12:01 AM EDT 12:01 AM DAMAGE TO RENTED MADE PREMISES(Ea Occurrence) $300,000 MED EXP(Any one person) $5,000 - PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $5,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS—COMP/OP AGG $1,000,000 PRO- POLICY JECT LOC PROFESSIONAL LIABILITY $1,000,000 OTHER: LEGAL LIAB TO PARTICIPANTS $1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) ANY AUTO BODILY INJURY(Per person) OWNED AUTOS SCHEDULED ONLY AUTOS BODILY INJURY(Per accident) HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) NOT PROVIDED WHILE IN HAWAII UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS-MADE AGGREGATE DED RETENTION WORKERS COMPENSATION AND N/A PER OTHER EMPLOYERS'LIABILITY _STATUTE ANY PROPRIETOR/PARTNER/ Y/N E.L.EACH ACCIDENT EXECUTIVE OFFICER/MEMBER EXCLUDED?(Mandatory in NH) E.L.DISEASE—EA EMPLOYEE If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE—POLICY LIMIT MEDICAL PAYMENTS FOR PARTICIPANTS PRIMARY MEDICAL EXCESS MEDICAL DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Abuse,Molestation, Harassment or Sexual Conduct Defense Cost Reimbursement—Limit$100,000 Certified Instructor of:Aerobics,Personal training CERTIFICATE HOLDER CANCELLATION Evidence of Coverage SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE �{ / ?tq,— Coverage is only extended to U.S.events and activities. **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 ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD