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DocuSign Envelope ID:C9E84AFC-1 B8F-4774-8ACB-F00B2751 F1 F2 <br /> Ac's CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) <br /> �►...-' 06/27/2017 <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 REPRESENTATIVE <br /> OR PRODUCER,AND THE CERTIFICATE HOLDER. <br /> IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If <br /> SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this <br /> certificate does not confer rights to the certificate holder in lieu of such endorsement(s). <br /> PRODUCER CONTACT NAME: Mass Merchandising Underwriting <br /> K&K Insurance Group,Inc. PHONE(A/CAI (AIC <br /> 1-800-506-4856 FAX 1-260-459-5590 <br /> 1712 Magnavox Way E- o,Ext): ,No>: <br /> Fort Wayne IN 46804 ADDRESS: info @fitnessinsurance-kk.com <br /> PRODUCER <br /> CUSTOMER ID: <br /> INSURER(S)AFFORDING COVERAGE NAIC# <br /> INSURED INSURER A: Nationwide Mutual Insurance Company 23787 <br /> Kevin James Kirk INSURER B: <br /> DBA: Functional Fitness INSURER C: <br /> 5311 Beaumont Drive <br /> Durham, NC 27707 INSURER D: <br /> A Member of the Sports,Leisure&Entertainment RPG INSURER E: <br /> INSURER F: <br /> COVERAGES CERTIFICATE NUMBER: W01055915 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 SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS <br /> LTR INSD WVD (MM/DD/YYYY) (MM/DD/YYYY) <br /> A X COMMERCIAL GENERAL LIABILITY X 6BRPG0000006028600 08/21/2017 08/21/2019 EACH OCCURRENCE $1,000,000 <br /> CLAIMS- 12:01 AM EDT 12:01 AM DAMAGE TO RENTED $300,000 <br /> MADE X OCCUR PREMISES(Ea Occurrence) <br /> MED EXP(Any one person) $5,000 <br /> PERSONAL&ADV INJURY $1,000,000 <br /> GENERAL AGGREGATE per year$5,000,000 <br /> GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS—COMP/OP AGG per year$1,000,000 <br /> POLICY JERO LOC PROFESSIONAL LIABILITY $1,000,000 <br /> OTHER: LEGAL LIAB TO PARTICIPANTS $1,000,000 <br /> AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT <br /> (Ea accident) <br /> ANY AUTO BODILY INJURY(Per person) <br /> OWNED AUTOS SCHEDULED BODILY INJURY(Per accident) <br /> ONLY AUTOS <br /> HIRED NON-OWNED PROPERTY DAMAGE <br /> AUTOS ONLY AUTOS ONLY (Per accident) <br /> NOT PROVIDED WHILE IN HAWAII <br /> UMBRELLA LIAB OCCUR EACH OCCURRENCE <br /> EXCESS LIAB CLAIMS-MADE AGGREGATE <br /> DED n RETENTION <br /> WORKERS COMPENSATION AND N/A PER OTHER <br /> EMPLOYERS'LIABILITY _STATUTE <br /> ANY PROPRIETOR/PARTNER/ Y/N E.L.EACH ACCIDENT <br /> EXECUTIVE OFFICER/MEMBER <br /> EXCLUDED?(Mandatory in NH) E.L.DISEASE—EA EMPLOYEE <br /> If yes,describe under DESCRIPTION <br /> OF OPERATIONS below E.L.DISEASE—POLICY LIMIT <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 /> Certified Instructor of: Personal training,Strength <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 <br /> Hillsborough,NC 27278 ACCORDANCE 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(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. <br /> The ACORD name and logo are registered marks of ACORD <br />